Medical Claims/Customer Service Technical Specialist (TPA/Ins)
Zenith-American - Las Vegas, NV

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We are currently seeking an experienced Medical Claims/Customer Service Technical Specialist for our Las Vegas, NV location. This position p erforms technical review, investigation and benefit determination of claims; audits claims, and provides customer service support for claims, pension and eligiblity and/or other departments as needed, in accordance with Company guidelines, client needs, and legislative requirements.


1. Reviews and interprets new benefit plans and/or benefit plan changes, provides documentation to assist IT with programming such changes, tests benefit changes/implementations, develops resource materials and acts as a resource for staff and management.

2. Performs claims system maintenance, including network and provider changes/updates and coordination of data uploads and transfers with IT.

3. Performs technical review and analysis to determine benefit allowance and benefit category on all types of claims, including large dollar and technically complex claims.

4. Assists in responding to inquiries and requests from clients, government agencies, unions, participants, attorneys, and consultants.

5. Investigates, evaluates and generates reports related to stop-loss, accident, medical malpractice, subrogation, and/or Worker’s Compensation cases for third party recovery.

6. Handles provider appeals through research and documentation, coordinates with vendors, and generates denial and/or approval letters.

7. Reviews processed claims, including hospital, medical, dental, vision, prescription, and timeloss for accuracy, HIPAA and DOL compliance, and appropriateness of benefits paid.

8. Compiles audit information, provides progress reports and training, and makes recommendations to management as appropriate.

9. Participates in developing customer service and claims processing policies, procedures and training.

10. Handles refunds, voids, overpayments, claim adjustments, responses to general correspondence, file audits, and monthly report generation

11. Maintains communications and effective working relationships with clients, government agencies, unions, participants, attorneys, and consultants.

12. Performs other similar and related duties as required.



1. High school diploma or GED.

2. Three to five years of claims and customer service experience, processing all types of claims, preferably in a TPA environment.

3. Experience in implementing/maintaining plan benefits within claims processing systems

4. Proficient PC skills including intermediate Microsoft Word, Excel and Outlook skills.

5. Excellent verbal and written communication and strong interpersonal skills.

6. Proven attention to detail, follow-through skills and problem solving skills.

7. Strong knowledge of self-administered plans is preferred.

8. Prior multi-employer and Taft-Hartley trust fund experience preferred

This is a full-time, non-exempt position. Zenith American offers great opportunity, professional client services teams, and competitive pay and benefits including 401(k), paid time off (PTO) plan and more. Send cover letter and resume referencing 209-2012 to [Click Here to Email Your Resumé] or fax to (206) 216-3486, ; Equal Opportunity Employer

Zenith American Solutions (formed by the merger of Zenith Administrators and American Benefit Plan Administrators) is a premier, national third party-administrator (TPA) for employee benefit plans. We serve as administrator, manager or technology service vendor for corporate employers, government entities, trade associations, and Taft-Hartley benefit trust funds, through our national network of service centers. We currently have 1200+ employees located in 36 offices across the nation. We combine technology and proven practices with national resources and a local presence for our clients. Come and find out about the great things going on at Zenith American.

Zenith-American - 2 years ago - save job
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