Claims QR Technician

Position Summary

The Claims Quality Review Technician is responsible for performing detailed quality reviews of processed claims to ensure accuracy and compliance with eligibility rules, benefits paid, client requirements and applicable legislative and regulatory guidelines.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities

• Reviews processed claims, including hospital, medical, dental, vision, prescription and time loss to confirm accuracy and appropriate adjudication of benefits.
• Identify and document quality trends, provide feedback, and assist management in monitoring processing performance against established standards.
• Reviews and interprets new benefit plans and/or benefit plan changes, develops resource materials and acts as a resource for staff.
• Conducts training for new and current employees on claims adjudication, contract language, benefit interpretation, claims QR process and departmental procedures.
• Collaborate with internal partners to resolve complex claim issues and support continuous improvement.
• Performs other duties as assigned.

Minimum Qualifications

• High school diploma or GED required
• 5+ years of related experience, including claims processing, training and/or claims quality review.
• Strong understanding of claims processing guidelines and benefit plan structures, and regulatory requirements.
• Demonstrated analytical, research, and problem-solving abilities with strong attention to detail.
• Working knowledge of CPT, HCPC and ICD-10 coding
• Proficiency in Microsoft Word, Excel and Outlook.

Preferred Qualifications

• Experience working in a Taft-Hartley environment
• Prior quality assurance or audit -focused experience
• Familiarity with automated claims platforms.

*Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.

Working Conditions/Physical Effort

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift 15 pounds at times.

Disability Accommodation

Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at - , and we would be happy to assist you.

Zenith American Solutions

Real People. Real Solutions. National Reach. Local Expertise.

We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.

Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.

We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American

We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more

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