Claims Investigative Examiner

Blue Cross of Idaho•Bozeman, MT

26d•$60,048 - $84,069

About The Position

Blue Cross of Idaho is seeking a Claim Investigator Examiner who will conduct claim reviews and investigations of health insurance fraud, waste, and abuse and processes the claims to reflect the outcome of the review and investigations. Activities and programs may include but are not limited to claim auditing, overpayment recovery activities, data mining, subrogation, third party liability (TPL), and coordination of benefits (COB). We are looking for an Examiner with: Experience: 5 years processing complex claims and adjustments What a day may look like: Participate in the development of payment accuracy audit methods, business rules, policies, and procedures. Perform audits of billing, clinical, and other records. Interpret, apply, and compare records with company contracts, policies, legal, and regulatory requirements. Review and investigate claims identified by anomaly data models, fraud detection software, and other data sources, to identify incorrect reimbursement or substantiate patters of suspected activity. Review claim and determines denial, acceptance, or a need for further investigation. Review existing claims for errors and omissions. Process complex claims, coordination of benefits, and claims adjustments. Ability to work well under pressure in a complex and rapidly changing environment. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads. Ability to work independently and as a team member. May perform coaching and mentor employees, as necessary. Researcher projects, as assigned. Perform other duties and responsibilities as assigned.

Requirements

5 years processing complex claims and adjustments
Ability to work well under pressure in a complex and rapidly changing environment.
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads.
Ability to work independently and as a team member.

Nice To Haves

Certified Professional Coder (CPC)
Facility coding experience
Ability to read medical records and coding
Strong creative and analytical thinking
Strong problem solving
Excellent verbal and written communication
Excellent interpersonal skills
Ability to research and navigate the system

Responsibilities

Participate in the development of payment accuracy audit methods, business rules, policies, and procedures.
Perform audits of billing, clinical, and other records.
Interpret, apply, and compare records with company contracts, policies, legal, and regulatory requirements.
Review and investigate claims identified by anomaly data models, fraud detection software, and other data sources, to identify incorrect reimbursement or substantiate patters of suspected activity.
Review claim and determines denial, acceptance, or a need for further investigation.
Review existing claims for errors and omissions.
Process complex claims, coordination of benefits, and claims adjustments.
May perform coaching and mentor employees, as necessary.
Researcher projects, as assigned.
Perform other duties and responsibilities as assigned.