Clinical Claims Consultant

The Clinical Claims Consultant will review complex claims and situations, making informed decisions that may require deviating from normal guidelines and interpreting contracts or benefit amounts. This role involves providing training and mentoring to less experienced claims staff, managing appeal reviews and responses with a focus on risk mitigation and customer experience, and updating claims processing guidelines to meet regulatory or contractual changes. The consultant will also assist in developing and implementing improvement processes, refer cases to legal and CSI, represent the company in legal matters surrounding claims decisions, and participate in department or company projects and special initiatives.