Claims Specialist I

Blue Cross and Blue Shield of Louisiana • Remote-LA, LA

1d

About The Position

The Claims Specialist I supports the claims unit by processing claims edits, determining primacy for Coordination of Benefits (COB), adjusting previously paid claims, and initiating recovery procedures for overpaid claims. The role is accountable for complying with laws and regulations associated with its duties. It does not manage people and reports to the Supervisor, Claims Operations.

The specialist reviews, researches, and updates claims, including recalculating benefits, processing edits, and initiating refund requests in accordance with contractual benefits and provider reimbursement rules. The role works with internal departments and external parties—including providers, members, lawyers, groups, insurance companies, and other plans—to establish accurate claim records and resolve coverage coordination matters. It may require requesting medical records.

The position requires reviewing quality audits for correction or routing within 48 hours, researching and correcting COB records, and communicating discrepancies when Medicare has incorrectly determined primacy. The specialist may also assist with training, implementations, documentation, and other duties as assigned. Work is performed in a normal, clean office environment with normal noise levels and is predominantly completed while standing or sitting. Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without employer-sponsored immigration support.

Requirements

• High school diploma or equivalent.
• Six months of experience in medical claims or health insurance-related customer service, or successful completion of BCBSLA adjustment or COB training.
• Strong analytical ability, oral and written communication skills, and human relations skills.
• Working knowledge of relevant PC software.
• Must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration or other employment-based immigration support.

Nice To Haves

• Residency in or relocation to Louisiana is preferred.
• Certification in Medical Billing or Coding may be used in lieu of experience.

Responsibilities

• Review, research, and update claims, including recalculating benefits, processing claims edits, and initiating refund requests according to contractual benefits or provider reimbursement rules.
• Learn and maintain a clear understanding of systems, applications, and procedures used to identify denial, edit, and processing codes and correctly process coordinated and non-coordinated claims.
• Communicate orally and in writing with internal and external contacts to provide accurate information for claim records, including information related to COB and medical record requests.
• Review quality audits and make corrections or route them within 48 hours of receipt, following departmental and corporate guidelines.
• Research and determine the correct order of benefits for payment and make necessary corrections to COB records.
• Notify appropriate departments when Medicare has incorrectly determined primacy and ensure a letter is generated to notify Medicare.
• Assist in other capacities as needed, including training, implementations, and documentation.
• Perform other job-related duties as assigned within the scope of responsibilities.
• Comply with laws and regulations associated with the role's duties and responsibilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED