Claims Specialist

Job TitleGuided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contributeAnnual incentive bonus plan based on company achievement of goalsTime away from work including paid holidays, paid time off and volunteer time offProfessional development courses, mentorship opportunities, and tuition reimbursement programPaid parental leave and adoption leave with adoption financial assistanceEmployee discount programJob Description SummaryUnder general supervision, assesses claim information, references contracts and performs calculations and other functions to accomplish the processing and payment of health insurance claims of a highly complicated nature. Interprets contract information and communicates with outside parties to obtain information and coordinate coverage. Performs research and adjustments on complex claims. Able to perform audit functions for line-of-business reviews.Job DescriptionEach duty and responsibility must be performed in accordance with individual performance scorecard production and quality standards.Successfully completes all training programs as required for the levelProcesses claims for multiple claim types.Performs in-depth research and adjustment functions for complex claims.Perform special projects and audit requests (e.g., complex accumulator reconsiderations, New Directions).Exemplifies professionalism by effectively composing and responding to phone and/or written inquiries from internal and external customers as business needs dictate.Sets up deducts, CLOV table entries, and other assigned finance functions.Mentors other Claims Examiners and is viewed as an expert for adjustmentsEnters record of inquiries and related correspondence in computerized tracking system.Researches applicable medical policy and corporate, divisional, and department policies and proceduresMaintains confidentiality of all regulated information in compliance with state and federal laws.Recognizes trends or common issues and raises to leadership as necessary. Provides solution options as appropriate.Recognizes and uses time management techniques appropriately to manage competing projects and priorities to meet customer needs and deliver on commitments in a timely manner.For FEP positions, processes all deferrals for FEP or edit corrections in computerized claims system.Performs complex FEP transactions (e.g., FEP Direct DDE, FEP Retro-enrollment, Out of Balance) and member appeals.Minimum QualificationsHigh school diploma or general education degree (GED).Minimum 1 year experience as a Blue KC Claim Examiner or Customer AdvocateAdvanced Keyboarding KnowledgeIntermediate knowledge of Microsoft OfficeAdvanced knowledge of computerized claims tracking systemSuccessful completion of training for Customer Service and Research and Adjustment functions.Preferred QualificationsAssociate's Degree from college or technical schoolBasic understanding of FacetsMedical terminology and ICD/CPT coding knowledge is preferred. (Level 1)Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.