Medical Review Claims Analyst

Blue Cross and Blue Shield of Kansas•Topeka, MO

5d•$24 - $29•Hybrid

About The Position

The Medical Review Claims Analyst is responsible and accountable for timely and accurate non-clinical reviews of Blue Cross and Blue Shield, National & Special, State, Federal, ITS claims and CSC inquiries to support corporate timeline goals. Responsible for accurate and timely responses to internal and external inquiries involving requests for explanation of contract coverage, coding, and claims payment. Responsible for identifying aberrant provider activity and opportunities for provider education and refer for appropriate intervention.

Requirements

High school diploma or equivalent required
Minimum 3 years' experience in BCBSKS Claims or Customer Service required
Minimum 2 years' experience in medical coding and AAPC certification required
Minimum 3 years' experience in medical coding required
Certified Coder-AHIMA or AAPC within three years of hire required
Must be self-directed with the ability to make independent decisions and prioritize personal and employee production activities.
Must have strong computer skills to operate effectively with company systems and programs.
Must be able to maintain a productive and professional relationship with multiple cross departmental and divisional teams.
Must have a strong analytical background.
Must be able to use medical terminology/medical diagnostic and procedure information, ICD-10, CPT, HCPCS coding to accurately review and complete claims activity.
Thorough knowledge of multiple product lines, contracts, and related operating policies with preference to FEP, Blue Choice, State of Kansas, and Interplan Teleprocessing System (ITS).

Nice To Haves

Thorough knowledge of multiple product lines, contracts, and related operating policies with preference to FEP, Blue Choice, State of Kansas, and Interplan Teleprocessing System (ITS).

Responsibilities

Responsible for independent non-clinical review of claims and inquiries using contracts, medical policies, internal guides, and desk process.
Ensure claims and inquiries are processed timely and accurately according to contract, corporate, and federal guidelines.
Responsible for identifying when a non-clinical review should be elevated to a higher level of review, i.e., nurse consultant, management, consultants.
Responsible for researching history, identifying appropriate guidelines, and formatting clear concise question(s) for claims needing nurse, management, or outside consultant review.
Responsible for providing support to internal staff (i.e., Marketing, Hotline, CSC), regarding questions about coding, claim processing, and pricing issues.
Responsible for maintaining current knowledge regarding coding, contract language, system editing, and pricing guidelines.
Responsible for identifying areas of aberrant utilization for provider education, guideline, and system changes.
Participates in department and cross-divisional teams.
Must follow URAC standards as required for essential job functions.