Analyst, Senior Claims Research

Bluecross Blueshield of South Carolina - Columbia, SC

Full-time - Mid Level

Columbia, SC

Insurance Carriers and Related Activities

About the position

As a Senior Claims Research Analyst at BlueCross BlueShield of South Carolina, you will play a crucial role in researching and resolving escalated, complex, and high-profile claims issues. This position requires you to serve as the primary point of contact (POC) for various professional and facility/hospital providers, ensuring that all claims issues are addressed efficiently and accurately. Your responsibilities will include assisting with escalated issues related to provider enrollment, medical review, appeals, and finance, all while striving to meet departmental goals. In this role, you will be expected to conduct thorough research to resolve high-profile claims issues, ensuring that any claims processing errors are corrected in accordance with the appropriate provider reimbursement contracts. You will also be responsible for communicating with providers to educate them on proper coding of claims, claims filing procedures, pricing concerns, and updates regarding benefits and systems. Additionally, you will troubleshoot and coordinate the resolution of any system processing errors that may arise. Your work will involve monitoring inventory reports to ensure timely resolution of claims, providing documentation for audit purposes, and maintaining open communication with assigned providers through weekly conference calls. This position is located onsite in Columbia, South Carolina, with standard working hours from 8:00 a.m. to 5:00 p.m., Monday through Friday.

Responsibilities

• Research and resolve high profile claims issues.
• Ensure claims processing errors are corrected according to the appropriate provider reimbursement contract.
• Research and resolve high profile issues including provider enrollment, medical review, appeals, and finance.
• Serve as Point of Contact for various providers to resolve all claims payment errors.
• Conduct weekly conference calls with assigned providers to ensure open communication on current issues.
• Communicate and educate providers on proper coding of claims, claims filing, pricing concerns, and contract questions.
• Determine if claims payment errors are the result of system issues.
• Troubleshoot and coordinate the resolution of system processing errors.
• Verify disbursement requests to ensure validity and appropriate documentation.
• Research rejected, transition, and paid status claims for validity and escalate as appropriate.
• Use various systems to complete research and monitor inventory reports for claims resolution.
• Provide documentation as requested for audit purposes.
• Provide written or telephone correspondence to resolve claims issues.

Requirements

• High School Diploma or equivalent.
• Comprehensive knowledge of claims payment policies and refund policies.
• Working knowledge of related claims software systems.
• Knowledge of medical terminology and coding as appropriate.
• Strong analytical skills and the ability to retrieve and research automated reports.
• Strong time management skills and adaptability to change.
• Strong verbal and written communication skills.

Nice-to-haves

• One year of Lead Claims Processing experience.

Benefits

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave - the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.