Claims Technical Review Specialist

Zenith American Solutions, Inc.

Claims Technical Review Specialist at Zenith American Solutions performing detailed reviews of health benefit claims. Ensuring accuracy, compliance, and processing efficiencies for all claims received.

Posted 7/24/2026full-timeRemote • California • 🇺🇸 United StatesMid-LevelSenior💰 $28 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims processing and adjudication principles, with a strong ability to analyze and interpret benefit plans and related documentation. Proficient in coordinating claims reviews and communicating effectively with stakeholders.

Highest-signal resume keywords

Claims ProcessingClaims AdjudicationMedical Claims TerminologyBenefit Plan InterpretationClaims Systems Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalysisBenefit Allowance CalculationClaims AdjustmentsTechnical ReviewDenial Letter Generation

Soft Skills

CommunicationResearchDocumentation

Tools & Technologies

MS Office ToolsClaims Systems

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

Group Health Benefit ClaimsHCFACPT-4ICD-10HCPCS

About the role

Key responsibilities & impact

Provides advanced technical review of all types of claims in accordance with Company guidelines
Performs technical review and analysis of all types of claims to ensure accuracy and adherence to prescribed procedures and plan guidelines
Coordinates appeals through research and documentation; generates denial or approval letters
Coordinates predetermination reviews and performs analysis to determine benefit allowance and benefit category
Processes refunds, voids, and overpayments, including related claim adjustments
Processes time loss claims and communicates with local union offices, medical service providers, employers, and members
Reviews and interprets new benefit plans or plan changes

Requirements

What you’ll need

High School Diploma or GED required
Three years of experience processing all types of group health benefit claims
In-depth knowledge of all aspects of benefits claims processing and claims adjudication principles and procedures
Excellent working knowledge of terminology related to processing medical and dental claims such as HCFA, CPT-4, ICD-10, HCPCS
Experience interpreting Plan documents and/or certificates of coverage related to benefits, eligibility, exclusions, and limitations
Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages
Strong working knowledge of Claims systems
Computer proficiency including MS Office Tools and Applications

Benefits

Comp & perks

Health insurance
Vision coverage
Dental coverage
401(k) plan with company match
Paid time off (PTO)
Opportunities for growth