Claims Technical Review Specialist (Healthcare Claims)

Location: Remote, PST - Zone 4

Compensation: $27.52 per hour

Company

hirify.global is an independent third-party administrator in the United States, providing claims and benefits administration services through a nationwide office network.

What you will do

• Review and analyze medical, dental, and other group health benefit claims, including large-dollar and technically complex cases.
• Coordinate appeals by researching claim details, preparing documentation, and generating approval or denial letters.
• Perform predetermination reviews and determine benefit allowances, categories, exclusions, and limitations.
• Manage third-party recovery activities, including communication with members, dependents, insurers, providers, and attorneys.
• Process refunds, voids, overpayments, claim adjustments, audits, reports, and time-loss claims.
• Interpret new or amended benefit plans, test benefits, create resource materials, and support staff and management.

Requirements

• High school diploma or GED.
• At least three years of experience processing group health benefit claims.
• In-depth knowledge of claims processing and claims adjudication principles and procedures.
• Working knowledge of medical and dental claims terminology, including HCFA, CPT-4, ICD-10, and HCPCS.
• Experience interpreting plan documents or certificates of coverage and using claims systems.
• Strong analytical, calculation, attention-to-detail, problem-solving, follow-through, communication, and computer skills, including Microsoft Office.

Nice to have

• Experience in a third-party administrator or Taft-Hartley environment.

Culture & Benefits

• Remote work aligned with the PST - Zone 4 schedule.
• Health, vision, and dental coverage.
• 401(k) retirement savings plan with company match.
• Paid time off and opportunities for professional growth.
• Work supporting high-quality service, mutual respect, and client and employee needs.