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.
• Cookorate 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.

Requirements

Must have a Bachelor's degree in Computer Science, Information Systems, Healthcare Informatics, or a related field. Relevant work experience in healthcare IT systems is preferred. Proficiency in healthcare claims processing, system management, and troubleshooting is required. Knowledge of ACES and its functionalities is essential. Familiarity with healthcare regulations and data privacy laws is necessary. Strong analytical and problem-solving skills are required. Excellent communication and customer service skills are essential. Ability to work independently and as part of a team is crucial. Experience with mainframe systems and SQL-based tools is beneficial.

Qualifications

Must reside in Kansas or Missouri or be willing to relocate as a condition of employment. Must be able to work remotely, hybrid, or onsite in accordance with our Telecommuting Policy.

Skills

• Healthcare claims processing
• System management and troubleshooting
• Data integrity and accuracy
• Project management
• Claims and eligibility system support
• Data analysis and reporting
• Customer support and training
• Compliance and regulations

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package.
• 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