Provider Disputes Quality Reviewer

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without employer‑sponsored immigration support; Louisiana Blue will not provide current or future employment‑based immigration sponsorship (including H‑1B, L‑1, O‑1, H‑1B1, E‑3, TN, J‑1, or F‑1 OPT/STEM OPT/CPT).

About the role

Position purpose: Review transactions processed by the Provider Disputes department to identify trends and systemic irregularities, improve quality performance, document reviews, and report results to management and processors. Ensure accurate and timely classification and processing of all levels of provider disputes across lines of business, and maintain compliance with accreditation guidelines and provider contractual agreements.

Reporting line: Reports to the Manager, Provider Disputes. This role does not manage people.

Key contacts: Various internal and external entities including all levels of BCBSLA personnel, attorneys, hospitals, and physician offices.

Responsibilities

• Conduct random reviews of claims disputes to promote consistency and determine corporate compliance with quality and timeliness standards set by the Blue Cross and Blue Shield Association, URAC, and provider contractual agreements.
• Maintain a log of all case reviews, reporting errors, trends, and best practices to management.
• Train, instruct, coach, and provide technical support to new and existing Provider Disputes team members.
• Define, execute, and administer assigned audits to ensure objectives are met, facts are properly presented, and adequate conclusions are reached with sound judgment and commitment.
• Meet targeted deadlines required by BCBSA, BCBSLA, and department management.
• Understand applicable operational processes, policies, procedures, and tools for processing key business transactions related to claims disputes, customer service, claims processing, administrative and medical appeals for all applicable lines of business.
• Resolve errors contested by specialists or leadership; recognize and adapt to changing guidelines and requirements diplomatically.
• Handle special projects and testing as assigned (e.g., Provider Disputes email box, Epic intake work queues) to help the department reach goals and maintain compliance.
• Maintain current knowledge of company policies and procedures; assist management in updating SOPs when requested.
• Perform other job‑related duties as assigned within scope of responsibilities.

Qualifications

Education

• High School Diploma or equivalent required.
• Bachelor’s degree in business, finance, accounting, healthcare administration, or related field preferred.
• Epic certification for Provider Disputes module and training certificate required within 1 year of employment.

Work experience

• 4 years of health insurance experience required.
• 2 years of experience in customer service, claims processing/adjustments (inpatient, outpatient, professional), or provider relations preferred.
• 3 years of experience reviewing claims for payment/processing accuracy on a quality management, administrative, or medical appeal level preferred.
• Experience manually pricing claims and reimbursement preferred.

Skills

• Demonstrated timely and accurate data maintenance with excellent quality‑driven methods.
• Strong attention to detail and record‑keeping skills.
• Ability to read and interpret benefits for all lines of business.
• Clear, concise report, proposal, and business correspondence writing.
• Strong oral and written communication, human relations, presentation, and public speaking skills.
• Thorough knowledge of claims processes and adjustment procedures.
• Working knowledge of relevant PC software (MS Word, Excel, Outlook) and corporate systems including Facets and Epic (Facets and Epic experience required).
• Strong analytical ability with logical, systemic, and investigative thinking.
• Ability to read and interpret reimbursement policies and benefits for all lines of business.
• Ability to work in a rapidly paced, ever‑changing environment.
• Ability to work independently with strong analytical and decision‑making skills.

Working conditions

• Job duties performed in a normal, clean office environment with normal noise levels.
• Work is predominantly done while standing or sitting.
• Requires the ability to comprehend, document, calculate, visualize, and analyze.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Job category: Insurance