• Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; • Adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. • Process provider refunds and returned checks. • Handle customer service inquiries and problems. • Perform adjustments across all dollar amounts on customer service platforms using technical and claims processing expertise. • Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. • Perform claim re-work calculations. • Follow through completion of claim overpayments, underpayments, and any other irregularities. • Process complex non-routine Provider Refunds and Returned Checks. • Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. • Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. • Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures. • Review and handle relevant correspondences assigned to the team that may result in adjustment to claims. • Provide job shadowing to lesser experience staff. • Utilize all resource materials to manage job responsibilities.