Provider Disputes Quality Reviewer

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

About The Position

The Provider Disputes Quality Reviewer 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, and ensures accurate, timely classification and processing of provider disputes across lines of business. The role also supports compliance with accreditation guidelines and provider contractual agreements related to claims disputes. This role does not manage people and reports to the Manager, Provider Disputes. It involves contact with internal and external parties, including BCBSLA personnel, attorneys, hospitals, and physician offices. 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 required.
Four years of health insurance experience required.
Demonstrated work experience showing timely and accurate data maintenance and quality-driven 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 and 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 applicable systems, including MS Word, Excel, Outlook, Facets, and Epic; Facets and Epic experience is required.
Strong analytical ability, including logical, systemic, and investigative thinking.
Ability to work in a rapidly paced and changing environment.
Ability to work independently and demonstrate analytical and decision-making skills.
Epic certification for the Provider Disputes module and a training certificate required within one year of employment.

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 at a quality management, administrative, or medical appeal level.
Experience manually pricing claims and reimbursement.
Residency in or relocation to Louisiana.

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 new Provider Disputes team members and coach or provide technical support to existing team members.
Define, execute, and administer assigned audits, ensuring objectives are met, facts are properly presented, and adequate conclusions are reached.
Meet deadlines established by BCBSA, BCBSLA, and department management.
Understand operational processes, policies, procedures, and tools used 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 Epic intake work queues, to support department goals and compliance.
Maintain knowledge and notes of current company policies and procedures so management can keep SOPs updated, and assist with SOP updates when requested.
Perform other job-related duties within the scope of responsibilities.