Claims Specialist II

Blue Cross and Blue Shield of Louisiana

20h•Onsite

About The Position

This role is responsible for the 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. The Claims Specialist II will analyze, investigate, and resolve problem cases, execute recovery processes, and complete special projects. This position is accountable for complying with all relevant laws and regulations. The role does not manage people and reports to the SUPERVISOR, CLAIMS OPERATIONS. Necessary contacts include various internal departments and staff, as well as external entities such as providers, members, lawyers, and other insurance companies.

Requirements

High School Diploma or equivalent required
2 years in medical claims processing required
Strong analytical ability, that includes strong logical, systemic, and investigates thinking.
Strong oral and written communication skills and human relations skills are necessary.
Working knowledge of relevant PC software.
Ability to prioritize multiple streams of work effectively.

Nice To Haves

Coordination of Benefits (COB) processing experience preferred
Residency in or relocation to Louisiana is preferred for all positions.

Responsibilities

Accurate processing of claims edits.
Determining primacy for the Coordination of Benefits (COB).
Adjusting previously paid claims.
Initiating procedures to recover funds on overpaid claims.
Analyzing, investigating, and resolving problem cases.
Executing recovery processes.
Completing special projects.
Complying with all laws and regulations associated with duties and responsibilities.
Reviews, researches, and makes necessary updates to claims that may include recalculation of benefits to previously processed claims, processing of claims edits, or initiation of refund requests.
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.
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.
Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines.
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.
Analyzes, investigates, resolves problem cases (to include COB records, adjusting previously processed claims and requesting refund of overpaid claims).
Reviews all previously paid claims to ensure consistency in payments to maximize recovery of overpayments.
Executes procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred.
Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation).
May complete special projects as assigned by Management due to internal audit findings, multiple provider status changes, and system errors.