Prepay Claims Review Specialist

: Position Description:

Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the “Best Places to Work in PA.”

The Prepay Claims Review Specialist ensures the accuracy and compliance of healthcare claims before payment is issued. This position involves detailed review and analysis of medical claims, provider documentation, and coding practices to verify proper adjudication in accordance with contractual agreements, regulatory guidelines, and company policies.

Responsibilities and Qualifications:

• Prepay Review: Review pended medical claims to ensure accuracy of coding, billing, and supporting documentation. Verify compliance with contract terms, provider agreements, and applicable regulations. Identify discrepancies, billing errors, or potential fraud and escalate as necessary to SIU investigator. Determine if claim and accompanying documentation require medical director review to determine medical necessity of services/procedures. Manage the processing control agent process to support flagging claims for identified providers and members that are under investigative review.
• Compliance and Guidelines: Ensure adherence to federal, state, and local healthcare laws, including CMS regulations and ICD-10/CPT/HCPCS coding standards. Ensure compliance with Capital Blue Cross policies and procedures. Stay current on regulatory updates and payer-specific policies.
• Collaborative Review: Work closely with internal teams, including medical directors, compliance team, provider engagement consultants, provider contracting, utilization management and claims processors, to resolve complex issues. Communicate with providers to request additional documentation or clarify billing inquiries.
• Reporting and Documentation: Maintain accurate documentation within SIU case tracking system and Utilization Management authorization system of claim reviews, findings, and actions taken. As requested, generate and analyze reports on claim trends, common errors, and operational insights for process improvement.
• Process Improvement: Recommend updates to policies, procedures, and systems to enhance claim processing efficiency and accuracy. Participate in training sessions and contribute to cross-departmental initiatives.

Skills:

• Proficiency in claims management systems and healthcare software.
• Proficiency in Microsoft Office products specifically Word and Excel with the ability to use basic Excel analytic functionality (Pivot tables, Formulas, Filters etc.).
• Excellent analytical, organizational, and time-management skills.
• Effective written and verbal communication skills for interaction with team members, providers, and leadership.
• Ability to work independently and maintain confidentiality of sensitive information.

Knowledge:

• Strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance billing practices.

Experience:

• 3 years' experience in claims processing, medical billing, or health insurance operations.
• Experience with prepay or post-pay claim reviews is highly desirable.

Education and Certifications:

• Certified Professional Coder (CPC) designation or must successfully complete CPC designation within 18 months of hire.
• High school diploma or equivalent required.
• Associate or bachelor's degree in healthcare administration, health information management, or related field preferred.

Work Environment:

• May require occasional travel to office (Harrisburg, PA) for training or team meetings.

About Us: We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.