Claims Specialist II

Role Description

Duties may include the following responsibilities or functions required to support the claims unit:

• 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.
• Accountable for complying with all laws and regulations associated with duties and responsibilities.

Qualifications

• High School Diploma or equivalent required.
• 2 years in medical claims processing required.
• Coordination of Benefits (COB) processing experience preferred.
• Strong analytical ability, including strong logical, systemic, and investigative 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.
• None Required for Licenses and Certifications.

Requirements

• Reviews, researches, and makes necessary updates to claims.
• Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes.
• Communicates with internal and external contacts to provide necessary and accurate information.
• Reviews quality audits for correction or routing within 48 hours of receipt.
• Researches, investigates, and determines the correct order of benefits for payment.
• Analyzes, investigates, resolves problem cases including adjusting previously processed claims.
• Executes procedures to recover funds from providers, subscribers, or beneficiaries.
• Steps in and assists in any other capacity as deemed necessary.
• May complete special projects as assigned by Management.

Benefits

• Resources to live well and be healthy.
• Opportunities for continued learning and skill development.
• Support for professional growth.
• Engagement in serving local communities.

Company Description

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions.

• Smoke and tobacco-free company properties.
• Drug Free Workplace policy.