Claims Systems Specialist

Job Summary

The Claims System Specialist will research problems in the Adjudication and Claim Entry System (ACES) as reported by ACES users and document problems in SBM. They will also develop, document, test, and approve system modifications, in tandem with Information Technology & Services (IT&S) staff, in ACES needed to resolve problems or develop new functionality. The role involves maintaining system security within ACES, acting as a liaison between IT&S and ACES users, and supporting claims and eligibility systems.

Responsibilities

• Maintain, update, and troubleshoot healthcare systems related to the claims programs and peripheral systems such as membership, BGT, Provider, etc.
• Ensure data integrity and accuracy in claims processing and eligibility systems.
• Cook with IT and operational teams to resolve system issues and ensure seamless functionality.
• Participate in system upgrade projects, implementing new functionalities and enhancements to support BCBSKS operations.
• Work with cross-functional teams, including developers, analysts, and business leaders, to ensure project deliverables are met.
• Aid in the development of project plans, timelines, and documentation for system improvements.
• Collaborate with claims and eligibility teams to identify system needs and ensure efficient processing of claims.
• Conduct testing and validation of system changes to ensure they align with guidelines and standards.
• Develop and update workflows to enhance system capabilities for claims processing.
• Develop and document needed business requirements to modify the existing ACES system, either to correct a problem or implement new functionality, and effectively communicate those requirements to IT&S staff to guide them in developing system changes to successfully achieve said needs.
• Write and execute queries in QMF (mainframe) or QMF for Workstation or other SQL-based tools or applications to identify problems and/or test claim situations.
• Provide technical assistance to internal teams and users on system functionalities.
• Train staff on the use of new or updated system features related to the programs.
• Create user manuals, guidelines, and training materials for healthcare system applications.
• Maintain ACES user specific security settings as the ACES system administrator.
• Ensure systems comply with federal healthcare regulations and data privacy laws (e.g., HIPAA).
• Stay up to date with FEP/ITS and lo

  Qualifications

  • Bachelor's degree in Computer Science, Information Systems, or a related field.
  • Minimum of 2 years of experience in healthcare IT or similar field.
  • Experience with healthcare claims processing systems and ACES.
  • Strong analytical and problem-solving skills.
  • Excellent communication and interpersonal skills.
  • Ability to work independently and as part of a team.
  • Knowledge of healthcare regulations and data privacy laws.

  Skills

  • Proficiency in healthcare claims processing systems.
  • Experience with ACES and other healthcare IT systems.
  • Strong analytical and problem-solving skills.
  • Excellent communication and interpersonal skills.
  • Ability to work independently and as part of a team.
  • Knowledge of healthcare regulations and data privacy laws.

  Benefits

  • Incentive pay program (EPIP)
  • Health/Vision/Dental insurance
  • 6 weeks paid parental leave for new mothers and fathers
  • Fertility/Adoption assistance
  • 2 weeks paid caregiver leave
  • 401(k) plan matching up to 5%
  • Tuition reimbursement
  • Health & fitness benefits, discounts and resources