Claims Examiner

Blue Cross of Idaho; Meridian (ID); On-site; USD 40,000 - 57,000; Full time

Benefits offered by this job

Paid time off

Paid holidays

401(k) matching

Employee assistance plan (EAP)

Education reimbursement

Job summary

Blue Cross of Idaho is seeking a COB Claim Examiner to determine COB and potential claim overpayments for members with multiple coverages. You will review claims, apply MSP rules, and decide on pay/deny outcomes within policy guidelines.

Responsibilities include verifying eligibility, coordinating with internal teams, and supporting recovery of overpayments while maintaining quality standards. A 1-year relevant experience is preferred.

Qualifications

• Knowledge of Medicare Secondary Payer (MSP) rules and Other Health Insurance (OHI) processing.
• Familiarity with medical terminology and claims terminology.
• Strong verbal and written communication skills.

Responsibilities

• Review and analyze claims to determine proper COB and payer responsibility.
• Apply MSP rules, MSP guidelines and OHI determinations.
• Identify whether Medicare is primary or secondary based on MSP scenarios.
• Evaluate and validate OHI information for accurate processing.
• Request and verify eligibility and coverage information with members and providers.
• Collaborate with internal teams to resolve claims issues.
• Assist with recovery and adjustment when COB determinations cause overpayments.
• Process claims within productivity and quality standards.

Skills

MSP rules knowledge

Medical terminology

Verbal & Written communication

Job description

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


• 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.