• Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. • Reviews pre-specified claims and those that exceed specialist adjudication authority or processing expertise. • Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost-containment measures to support accurate claim adjudication. • Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures. • Identifies and reports potential overpayments, underpayments, and other claim irregularities. • Performs claim rework calculations as needed. • Trains and mentors as needed to enhance team performance and technical proficiency. • Conducts outbound calls to obtain required information for claims or reconsideration requests.