• Review complex high-cost claims to determine financial and risk accuracy and conduct in-depth review of written dispute requests from providers for denied or incorrect payments based on contractual agreements.
• Assist junior staff on challenging cases.
• Identify trends and areas for improvement in the claims process.
• Conduct retrospective audits of paid claims, flagging overpaid claims for recovery.
• Prepare concise documentation and audit reports, including recommendations to claims management for improvements and corrective action plans.
• Mentor and coach new and existing staff on best practices and company policies.
• Ensure claims handling complies with company policies, industry regulations, and legal requirements.
• Perform other ad hoc duties as required.

Work effectively in an environment shaped by artificial intelligence (AI), machine learning, d...