About the position
The Claims Specialist at Arkansas Blue Cross and Blue Shield is responsible for resolving medical claims that are not automatically adjudicated by the claims processing system. This role requires timely and accurate resolution of claims according to divisional standards of quality and productivity. The specialist will engage in additional investigation or communication to obtain necessary information to complete the claims process. Various external factors such as peak filing seasons, system downtimes, inclement weather, holidays, and absenteeism can directly impact the volume of work for each specialist. To be successful in this position, the Claims Specialist must possess a high school diploma or equivalent, with a minimum of two years of college coursework or equivalent certification in relevant fields such as anatomy, medical terminology, math, or biology. Alternatively, candidates may qualify with at least one year of related office experience in claims processing, health insurance, or a medical office. The role also requires passing a company proficiency test known as the Claims Assessment. Essential skills for this position include strong oral and written communication abilities, interpersonal skills, sound judgment, decision-making capabilities, attention to detail, teamwork, and dependability. The Claims Specialist will be involved in various responsibilities, including claims processing, knowledge acquisition, and adherence to security and confidentiality requirements. Continuous learning and staying updated with changing procedures and standards are crucial for maintaining acceptable performance levels in this role.
Responsibilities
- Resolve medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner.
- Enter data into the system for claims processing.
- Review and interpret contract benefits for claims.
- Conduct edit and audit resolution for claims.
- Determine benefit eligibility for claims.
- Identify and research processing issues through systems and manuals.
- Route claims to other areas as necessary.
- Consult with internal staff and medical providers regarding claims.
- Generate correspondence and complete forms to obtain necessary information for claims.
- Undergo initial training, on-the-job training, and continuing education to stay current with processing procedures and standards.
- Ensure the security and confidentiality of records and information as per company guidelines.
- Adhere to segregation of duties guidelines to prevent or detect errors or irregularities.
Requirements
- High School diploma or equivalent.
- Minimum two (2) years' college coursework (48 semester hours) or equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field.
- Minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.
- Must pass company proficiency test: Claims Assessment.
- Strong oral and written communication skills.
- Strong interpersonal skills and sound judgment.
- Detail-oriented with strong decision-making abilities.
- Ability to work effectively in a team and demonstrate dependability.
Nice-to-haves
- Experience with ICD, CPT, and HCPS codebooks.
- Familiarity with corporate and professional manuals and guidebooks.
Benefits
- Tuition reimbursement for further education.
- Access to Club Blue, a free onsite gym.
- Green Leaf Grill, an onsite cafeteria promoting healthy eating.
- Incentives for wellness education and exercise programs.
