Resp & Qualifications
PURPOSE:
Under general supervision, reviews and adjudicates paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures.
ESSENTIAL FUNCTIONS:
- Examines and resolves non-adjudicated claims to identify key elements of processing requirements based on contracts, policies and procedures. Process product or system-specific claims to ensure timely payments are generated and calculate deductibles and maximums as well as research and resolve pending claims. The Claims Processor also use automated system processes to send pending claims to ensure accurate completion according to medical policy, contracts, policies and procedures allowing timely considerations to be generated using multiple systems.
- Does extensive research of procedures. May also apply training materials, emails and medical policy to ensure claims are processed correctly. Utilizes the quality team for assistance on unclear procedures and/or difficult claims and receives coaching from leadership. Ongoing developmental training to performing daily functions.
- Completes productivity data daily that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning, etc.
- Assists Customer Service Reps by providing feedback and resolving issues and answering basic processing questions.
QUALIFICATIONS:
Education Level: High School Diploma or GED.
Experience: 3 years claims experience required.
Preferred Qualifications:
- 3 years claims processing, billing or medical terminology experience.
Knowledge, Skills and Abilities (KSAs)
- Demonstrated communication skills both written and verbal.
- Demonstrated strong analytical skills.
- Demonstrated knowledge and understanding of claims systems and processes.
- Demonstrated reading comprehension of materials provided to adjudicate claims.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $36,720 - $67,320
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-AB1
High school diploma or GED; 3 years claims experience required; strong communication, analytical skills, and knowledge of claims systems; must be eligible to work in the U.S. without sponsorship.
Key Responsibilities
- adjudicating claims
- researching procedures
- resolving pending claims
Job Details
- Category: Business Operations
- Seniority: Mid Level
- Commitment: Full Time
- Workplace: Remote — United States
- Salary: USD 36,720 – 67,320 / year
- Languages: English
Benefits
- Retirement plan
About CareFirst BlueCross BlueShield
A health insurance company that processes claims and provides healthcare coverage. — Industry: Healthcare