Provider Disputes Quality Reviewer

Blue Cross and Blue Shield of Louisiana•Baton Rouge, LA

About The Position

This position reviews transactions processed by the Provider Disputes department to identify trends and systemic irregularities and improve quality performance. The reviewer documents reviews and reports results to management and processors, while ensuring accurate and timely classification and processing of provider disputes across lines of business. The role also helps ensure compliance with accreditation guidelines and provider contractual agreements related to claims disputes. The position does not manage people and reports to the Manager, Provider Disputes. It involves contact with internal and external parties, including BCBSLA personnel at all levels, attorneys, hospitals, and physician offices. Duties are performed in a normal, clean office environment with normal noise levels. Work is predominantly done 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.
Four years of health insurance experience.
Epic certification for the Provider Disputes module and a training certificate are required within one year of employment.
Demonstrated work experience in timely and accurate data maintenance and quality-driven work methods.
Attention to detail and strong record-keeping skills.
Ability to read and interpret benefits and reimbursement policies for all lines of business.
Ability to write clear, concise reports, proposals, and business correspondence.
Strong oral and written communication, human relations, presentation, and public speaking skills.
Thorough knowledge of the claims process and adjustment procedures.
Working knowledge of relevant PC software and systems, including MS Word, Excel, Outlook, Facets, Epic, and related corporate applications; Facets and Epic experience are required.
Strong analytical ability, including logical, systemic, and investigative thinking.
Ability to work in a rapidly paced and changing environment, work independently, and demonstrate analytical and decision-making skills.
Ability to comprehend, document, calculate, visualize, and analyze.
Must be authorized to work in the United States without employer-sponsored immigration or other immigration support.

Nice To Haves

Bachelor's degree in business, finance, accounting, healthcare administration, or a related field.
Two years of experience in customer service, claims processing or adjustments (inpatient, outpatient, professional, etc.), or provider relations.
Three years of experience reviewing claims for payment or processing accuracy in a quality management, administrative, or medical appeal role.
Experience manually pricing claims and reimbursement.
Residency in or relocation to Louisiana is preferred.

Responsibilities

Conduct random reviews of claims disputes to promote consistency and assess compliance with quality and timeliness standards established by the Blue Cross and Blue Shield Association, URAC, and provider contractual agreements.
Maintain a log of case reviews and report errors, trends, and best practices to management.
Instruct and coach new Provider Disputes team members and provide technical support to existing team members.
Define, execute, and administer assigned audits, ensuring objectives are met, facts are properly presented, and conclusions are adequate.
Meet deadlines required by BCBSA, BCBSLA, and department management.
Understand operational processes, policies, procedures, and tools for claims disputes, customer service, claims processing, and administrative and medical appeals across applicable lines of business.
Resolve errors contested by specialists or leadership and adapt diplomatically to changing guidelines and requirements.
Handle special projects and testing as assigned, including work involving the Provider Disputes email box and intake work queues in Epic.
Maintain knowledge and notes on company policies and procedures and assist management with updating SOPs when requested.
Perform other job-related duties within the scope of responsibilities.