Claims Examiner II

Blue Cross and Blue Shield of Nebraska•Remote Nebraska, NE

9d•Remote

About The Position

At Blue Cross and Blue Shield of Nebraska, the Claims Examiner II adjudicates healthcare claims using employer- and payer-specific policies and procedures. The role reviews claim data against CMS and billing guidelines, medical documentation and attachments when needed, and adjudication-system edits to determine whether claims and line items should be paid. The examiner may refer claims to specialized internal or external resources, coordinate with other departments, and is accountable to performance scorecards. The position also provides guidance to less experienced claims examiners. Applicants for this remote position must live in Nebraska or the local Omaha metro area. The examiner interprets adjudication rules to process or adjust complex claims, makes independent decisions on complex claims, and meets daily quality and production standards. The role reviews member and provider disputes, identifies potential issues with system or provider-contract configurations, communicates concerns for research and correction, and contributes feedback and process-improvement ideas. The examiner collaborates with teammates and business partners, supports less experienced associates, may assist with Claims Examiner I-level work in other lines of business, and participates in special projects as needed. Other duties may be assigned by Claims Leadership.

Requirements

High school degree.
Proficiency as a Claims Examiner I or relevant healthcare experience.
Excellent verbal and written communication skills.
Proficiency with MS Office applications.
Ability to collaborate with a team.
Ability to work with minimal supervision.
Creative thinking and good problem-resolution skills related to healthcare claim adjudication.
Strong work ethic and ability to multitask when needed.
For the remote position, must live in Nebraska or the local Omaha metro area.

Responsibilities

Interpret claim adjudication rules to process and/or adjust complex claims.
Analyze claims for accuracy and completeness and determine benefits based on member and provider contracts, payment rules, eligibility, coordination of benefits requirements, and provider status.
Use multiple systems and screens to obtain and record claim information.
Follow relevant policies and procedures.
Review medical records, authorization information, and member benefit coverage to determine payment liability.
Process claims within quality and production standards.
Independently determine the appropriate adjudication of complex claims.
Review member and provider claim disputes, including urgent internal department requests.
Learn to assist other lines of business with Claims Examiner I-level work.
Identify concerns that may compromise member, provider, or group satisfaction.
Identify claims that may indicate problems with claim-system or provider-contract configuration and communicate issues for research and correction.
Provide feedback to help identify quality trends and opportunities.
Collaborate with teammates and business partners to meet productivity and accuracy standards and support process improvements.
Participate in special projects as needed.
Suggest ways to improve member and provider satisfaction.
Partner with less experienced associates to improve team and division knowledge and performance.
Promote teamwork.
Perform other duties assigned by Claims Leadership.
Provide guidance to less experienced claims examiners.