Claims Examiner

Capital Blue Cross•Harrisburg, PA

About The Position

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” This position is responsible for the coding and total processing of claims and triaging claim adjustments generated by our providers and subscribers or requested via Customer Service, for all lines of business. Processes claims utilizing established policies and procedures to review and correct error and warning messages. Research claims and ensures proper adjudication.

Requirements

Ability to communicate effectively and professionally with personnel, in both written and verbal form.
Must possess a strong attention to detail and an interest in preventing errors
Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, and etc.) as well as possess excellent keyboarding skills
Demonstrate ability to be dependable and professional.
Demonstrate intrinsic initiative and time management skills
Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed
Ability to accept feedback, learn, and adapt from guidance to be successful
Ability to adapt to constant changing priorities and keeping daily responsibilities on task
Ability to manage workload and ensure all tasks are completed within established timeframes
Must be willing and able to work possible mandatory overtime as needed based on business needs
Must be able to meet quality, productivity, and behavior expectations
Must possess basic reading and arithmetic skills (reading and math comprehension)
Must have a high school diploma or GED.

Nice To Haves

Preferred familiarity with provider billing documents (including in/out of state hospitals doctor, pharmacy, and suppliers) in order to code and enter appropriate data from each bill.
Preferred familiar with medical terminology in order to correctly code and enter the appropriate ICD-10CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code.
Preferred knowledge of both manual and automated aspects of claims processing and Image systems.
Preferred knowledge of claims payment policies and benefits.
Preferred competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.)
Preferred FACETS claims Coding
Preferred Facets claims processing
Preferred WorkDesk Imaging
Preferred Facets Customer Service Application

Responsibilities

Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors.
Reviews and corrects on-line edit errors by interpreting generated warning messages.
Uses appropriate systems to research and accurately process claims. Researches appropriate reference documents and imaged claims to make coding and payment decisions.
Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions.
May identify and report possible system or Image problems to CPR or Supervisor so that corrective action may be taken.
All other duties and assignments as directed.