Claims Examiner

Blue Cross of Idaho is seeking a COB Claim Examiner to utilize claims systems and established resources to determine coordination of benefits and potential claim overpayments for members covered by more than one health coverage. Determine whether to return, deny or pay claims following organizational policies and procedures.

We are looking for a Claim Examiner with:

Experience: 1-year relevant experience

What a day may look like:

• Review and analyze claims to determine proper Coordination of Benefits (COB), including primary and secondary payer responsibility
  
• Apply Medicare COB rules, including Medicare Secondary Payer (MSP) guidelines and Other Health Insurance (OHI) determinations.
  
• Identify situations where Medicare is primary vs. secondary based on MSP provisions (e.g., working aged, ESRD, disability, liability, no-fault, and workers' compensation cases).
  
• Evaluate and validate OHI information to ensure accurate claims processing and reimbursement.
  
• Request and verify eligibility and coverage information from members, providers, and other insurance carriers.
  
• Collaborate with internal teams (e.g., Payment Integrity, Recovery, Customer Service) to resolve claims issues.
  
• Assist with recovery and adjustment of claims when incorrect COB determinations result in overpayment.
  
• Process claims accurately within established productivity and quality standards.
  

We are also looking for:

• Basic knowledge of Medicare Secondary Payer (MSP) rules and Other Health Insurance (OHI) processing.
  
• Knowledge of medical terminology
  
• Ability to complete assigned individual tasks within scope
  
• Ability to follow detailed policies, guidelines, and regulatory requirements.
  
• Verbal & Written Communication
  

As of the date of this posting, a good faith estimate of the current pay range is $19.45 - $27.23. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).

The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.