Claims Specialist I

Blue Cross and Blue Shield of Louisiana

2d•Onsite

About The Position

This role is responsible for supporting the claims unit by accurately processing claims edits, determining primacy for Coordination of Benefits (COB), adjusting previously paid claims, and initiating procedures to recover funds on overpaid claims. The position requires compliance with all associated laws and regulations. This role does not manage people and reports to the SUPERVISOR, CLAIMS OPERATIONS. Necessary contacts include various internal departments and staff such as Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Enrollment and Billing, Administrative Services, and District Offices, as well as external entities like Providers, Members, Lawyers, Groups, the Commissioner of Insurance, other insurance companies, and other Plans.

Requirements

High School Diploma or equivalent required
6 months of experience in medical claims or health insurance-related customer service or the successful completion of BCBSLA adjustment or COB training
Strong analytical ability, oral and written communication skills and human relations skills are necessary.
Working knowledge of relevant PC software.

Nice To Haves

Certification in Medical Billing or Coding can be used in lieu of experience

Responsibilities

Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims.
Reviews, researches, and makes necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.
Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) in order to process both coordinated and non-coordinated claims correctly.
Requesting of medical records may be required.
Communicates, both orally and in writing, with internal and external contacts in order to provide necessary and accurate information for the establishment of sound claim records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc.
Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
Researches, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records.
Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare.
Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation).
Perform other job-related duties as assigned, within your scope of responsibilities.