Claims Specialist

Job Description

Under general supervision, assesses claim information, references contracts and performs calculations and other functions to accomplish the processing and payment of health insurance claims of a highly complicated nature. Interprets contract information and communicates with outside parties to obtain information and coordinate coverage. Performs research and adjustments on complex claims. Able to perform audit functions for line-of-business reviews.

• Successfully completes all training programs as required for the level
• Processes claims for multiple claim types.
• Performs in-depth research and adjustment functions for complex claims.
• Performs special projects and audit requests (e.g., complex accumulator reconsiderations, New Directions).
• Exemplifies professionalism by effectively composing and responding to phone and/or written inquiries from internal and external customers as business needs dictate.
• Sets up deducts, CLOV table entries, and other assigned finance functions.
• Mentors other Claims Examiners and is viewed as an expert for adjustments
• Enters record of inquiries and related correspondence in computerized tracking system.
• Researches applicable medical policy and corporate, divisional, and department policies and procedures.
• Maintains confidentiality of all regulated information in compliance with state and federal laws.
• Recognizes trends or common issues and raises to leadership as necessary. Provides solution options as appropriate.
• Recognizes and uses time management techniques appropriately to manage competing projects and priorities to meet customer needs and deliver on commitments in a timely manner.
• For FEP positions, processes all deferrals for FEP or edit corrections in computerized claims system.
• Performs complex FEP transactions (e.g., FEP Direct DDE, FEP Retro-enrollment, Out of Balance) and member appeals.

Qualifications

• High school diploma or general education degree (GED).
• Minimum 1 year experience as a Blue KC Claim Examiner or Customer Advocate
• Advanced Keyboarding Knowledge
• Intermediate knowledge of Microsoft Office
• Advanced knowledge of computerized claims tracking system
• Successful completion of training for Customer Service and Research and Adjustment functions.

Preferred Qualifications

• Associate’s Degree from college or technical school
• Basic understanding of Facets
• Medical terminology and ICD/CPT coding knowledge is preferred. (Level 1)

Benefits

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include: Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute Annual incentive bonus plan based on company achievement of goalsTime away from work including paid holidays, paid time off and volunteer time offProfessional development courses, mentorship opportunities, and tuition reimbursement programPaid parental leave and adoption leave with adoption financial assistanceEmployee discount program