Claims Systems Specialist

Blue Cross and Blue Shield of Kansas•New York, OK

7d•$27 - $34•Hybrid

About The Position

The Claims System Specialist will research problems in the Adjudication and Claim Entry System (ACES) as reported by ACES users and document problems in SBM. This role involves developing, documenting, testing, and approving system modifications in ACES, in tandem with Information Technology & Services (IT&S) staff, to resolve problems or develop new functionality. The specialist will also maintain system security within ACES and act as a liaison between IT&S and ACES users. This position is eligible to work remotely, hybrid, or onsite in accordance with the Telecommuting Policy, and applicants must reside in Kansas or Missouri or be willing to relocate.

Requirements

High school graduate or equivalent required.
Must have 1 year experience in Blue Cross and Blue Shield of Kansas claims processing with a thorough knowledge of the existing ACES system.

Nice To Haves

Bachelor's degree with emphasis in Computer Science, Business Administration, or Accounting is preferred.
Experience using the principles of system testing, how to thoroughly test a system when changes occur to include setting up test cases, ensuring extreme values are tested in all cases and verifying the results of both valid and invalid input, is preferred.
Training to adjudicate claims on multiple lines of business is preferred.
Experience or knowledge in data processing techniques is preferred but not required.
Must be organized, detail oriented and be able to prioritize and work on multiple different topics within any one given day.
Existing ability to use QMF is preferred, but not required.
Existing ability to use Rally for user story documentation is preferred.
Existing ability to use QA Complete for test case documentation is preferred.
Existing knowledge of MTM, FEP PIP, LDLA, BlueCard Scorecard and State of Kansas Performance Guarantees for claims transactions is preferred.
Existing knowledge of peripheral systems such as Membership, Provider, BGT, Prime, FEP, ITS, ICD Enterprise Database, etc., is preferred but not required.
Existing knowledge of the accumulator integration processes with Prime and Caremark is preferred, but not required.

Responsibilities

Maintain, update, and troubleshoot healthcare systems related to the claims programs and peripheral systems such as membership, BGT, Provider, etc.
Ensure data integrity and accuracy in claims processing and eligibility systems.
Coordinate with IT and operational teams to resolve system issues and ensure seamless functionality.
Participate in system upgrade projects, implementing new functionalities and enhancements to support BCBSKS operations.
Work with cross-functional teams, including developers, analysts, and business leaders, to ensure project deliverables are met.
Assist in the development of project plans, timelines, and documentation for system improvements.
Collaborate with claims and eligibility teams to identify system needs and ensure efficient processing of claims.
Conduct testing and validation of system changes to ensure they align with guidelines and standards.
Develop and update workflows to enhance system capabilities for claims processing.
Develop and document needed business requirements to modify the existing ACES system, either to correct a problem or implement new functionality, and effectively communicate those requirements to IT&S staff to guide them in developing system changes to successfully achieve said needs.
Analyze healthcare data from the system to identify trends, issues, and opportunities for improvement.
Generate regular and ad-hoc reports to support decision-making by management.
Monitor system performance and produce detailed analysis for system audits or compliance checks.
Write and execute queries in QMF (mainframe) or QMF for Workstation or other SQL-based tools or applications to identify problems and/or test claim situations.
Provide technical assistance to internal teams and users on system functionalities.
Train staff on the use of new or updated system features related to the programs.
Assist in creating user manuals, guidelines, and training materials for healthcare system applications.
Maintain ACES user specific security settings as the ACES system administrator.
Ensure systems comply with federal healthcare regulations and data privacy laws (e.g., HIPAA).
Stay up to date with FEP/ITS and local guidelines and health plan requirements, ensuring system modifications adhere to these standards.
Perform and coordinate BCBSA partner plan testing requirements with other Blue Cross and Blue Shield plans for ITS system changes as assigned by management.
Serve as primary point of contact for Blue Cross and Blue Shield partner plans including: Contacting other plans regarding claims problems to coordinate resolution of problems between plans. Supporting partner plan testing as a Host or Home plan. Evaluating communications from other plans and providers to determine the impact on the Kansas plan and initiate any activity required. Determine how to implement and integrate new ITS products pertaining to ACES.
Serve as a liaison between IT and operations teams, ensuring smooth communication and system functionality across departments.
Communicate system issues and updates to key stakeholders in a timely manner.
Serve as an ACES system expert to all employees of the company and research and resolve all questions submitted by fellow employees.
Represent the Claims area in company meetings with all levels of employees, in a professional manner, as a subject matter expert.