Claims Specialist II

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

3d•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 position involves analyzing, investigating, and resolving problem cases, executing recovery processes, and completing special projects. The Claims Specialist II must comply with all associated laws and regulations. Residency in or relocation to Louisiana is preferred.

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

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

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, 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.
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 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.
Analyzes, investigates, resolves problem cases (to include COB records, adjusting previously processed claims and requesting refund of overpaid claims).
Reviews all previously processed claims to ensure consistency in payments to maximize recovery of overpayments following corporate and departmental guidelines to ensure financial stability.
Executes procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred to ensure accuracy of claims processing and financial stability.
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 following corporate and departmental guidelines to ensure financial stability and customer satisfaction.
Perform other job-related duties as assigned, within your scope of responsibilities.