Claims Examiner II: Remote Nebraska

Blue Cross and Blue Shield of Nebraska; Lincoln (NE); Remote; USD 42,000 - 54,000; Full time

Job summary

Blue Cross and Blue Shield of Nebraska is seeking a Claims Examiner I to adjudicate healthcare claims, review data against CMS and billing guidelines, and ensure proper benefit coverage. This remote role requires Nebraska residency and offers opportunities to develop expertise while collaborating with a dedicated team.

You will analyze claims, use multiple systems, and help maintain production and quality standards, while guiding less experienced colleagues and contributing to process

Qualifications

• Proficiency with MS Office applications.
• Experience in healthcare claims adjudication is required or strongly preferred.
• Strong attention to detail and accuracy.
• Good problem resolution skills for healthcare claim adjudication.
• Clear communication and collaboration with team members.

Responsibilities

• Adjudicate healthcare claims using employer and payer policies and procedures.
• Review data in the claims processing system and compare with CMS and billing guidelines.
• Review medical claim attachments to determine medical necessity and benefit coverage.
• Review adjudication software’s claim and line item edits for payment determinations.
• Forward claims to specialized internal or external resources as needed.
• Correspond with other departments to process claims.
• Meet performance metric scorecards and quality standards.
• Provide guidance to less experienced claims examiners.
• Interpret adjudication rules to process and adjust complex claims.
• Analyze claims for accuracy considering member/provider contracts and COB.
• Use multiple systems to obtain and record claim information.
• Follow all relevant policies and procedures.
• Review medical records, authorization information, and benefits coverage to determine liability for payment.
• Process claims within production standards.
• Make independent determinations on complex claim adjudication.
• Review disputes submitted by members and providers.
• Assist other lines of business for Claims Examiner I level work.
• Identify issues with claim system or provider contracts and provide feedback on trends.
• Collaborate with teammates and partners to meet productivity and accuracy targets.
• Participate in special projects and coach others.

Skills

MS Office

Claims adjudication

Attention to detail

Problem solving

Communication

Job description

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

Candidates applying to this remote position are required to live in the state of Nebraska or local Omaha metro area.

Job Responsibilities

• Adjudication of healthcare claims utilizing employer and payer specific policies and procedures.
• Responsible for reviewing the data in the claims processing system and compare with corresponding CMS and billing guidelines.
• Responsible for reviewing medical claims attachments when necessary to determine if services rendered was medically appropriate and benefit coverage criteria has been met.
• Responsible for reviewing adjudication software system's claim and line item edits for determination of whether to pay claim/line item(s).
• May forward claims to specialized internal and external resources.
• Corresponds with other departments as necessary to process claims.
• Accountable to performance metric scorecards.
• Provide guidance to less experienced claims examiners.
• Responsible for interpreting claim adjudication rules to process and/or adjust complex claims.
• Analyze claims for accuracy and completeness to determine benefits based on specific member and provider contracts, payment rules, eligibility status, COB requirements and provider status in a timely manner.
• Efficiently use multiple systems and screens to obtain and record claim information.
• Follow all relevant policies and procedures.
• Review medical record documentation, authorization information and member benefit coverage to determine the extent of liability for payment.
• Process claims within quality and production standards.
• Make determinations on the appropriate adjudication of complex claims independently.
• Review claim disputes submitted by member and providers to include urgent internal department requests.
• Take initiative and learn to assist other lines of business for Claims Examiner I level work.
• Identify claims that suggest a potential issue or problem with the claim system configuration or provider contract configuration.
• Provide feedback to ensure identification of quality trends and opportunities.
• Work collaboratively with teammates within the department and with all other business partners to achieve productivity standards and adhere to accuracy standards through process improvements.
• Participate in special projects, as needed.
• Partner with less experienced associates to improve the overall knowledge and performance of the team and the division as a whole.
• All other duties as assigned by Claims Leadership.

Qualifications

• Proficiency as a Claims Examiner I or relevant healthcare experience.
• Proficiency with MS Office applications.
• Must be able to work with minimal supervision.
• Creative thinker with good problem resolution skills related to the healthcare claim adjudication.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability.