Claims Specialist 1

Arkansas Blue Cross and Blue Shield; Arkansas; Remote; USD 28,000 - 34,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking a Claims Specialist to resolve non-auto-adjudicated medical claims in a remote capacity. The role emphasizes timely, accurate processing aligned with divisional standards, with occasional impact from peak seasons and system downtime.

The ideal candidate will have a High School Diploma (or equivalent) plus college coursework or related office experience, strong communication, and organizational skills to handle detailed claim reviews and provider

Qualifications

• Must pass company proficiency test: Claims Assessment.
• Minimum two (2) years' college coursework (48 semester hours) or equivalent certification with emphasis in anatomy, medical terminology, math, biology, or related field.
• Or minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.

Responsibilities

• Claims Processing: pay or deny pended claims (not auto-adjudicated) by entering data, reviewing contracts, and resolving edits.
• Knowledge/Continuous Learning: training, on-the-job learning, and continuing education to stay current with procedures and systems.
• Other duties: as assigned

Skills

Clinical Judgment

Computer Skills

Critical Thinking

Customer Service

Decision Making

Evaluating Information

Interpersonal Communication

Oral Communications

Organizing

Process Information

Reading Comprehension

Researching

Time Management

Education

High School Diploma

48 Semester Hours / related field

Job description

Job SummaryThe Claims Specialist resolves medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner according to divisional standards of quality and productivity. Resolution may include additional investigation or communication in order to obtain necessary information to complete the claim. Outside issues such as peak filing season, systems down time, inclement weather, holidays, and absenteeism may directly affect the volume of work for each SpecialistRequirementsEDUCATIONHigh School diploma or equivalent.EXPERIENCEMinimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field. OR minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.Must pass company proficiency test: Claims AssessmentESSENTIAL SKILLS & ABILITIESOral & Written CommunicationsStrong Interpersonal skillsSound JudgementDecision MakingDetail-OrientedTeamworkDependabilityLOCATIONThis role is 100% remote. Preference will be given to current employees and candidates who reside in Arkansas.Skills• Clinical Judgment• Computer Work• Critical Thinking• Customer Service• Decision Making• Evaluating Information• Interpersonal Communication• Oral Communications• Organizing• Process Information• Reading Comprehension• Researching• Time ManagementResponsibilities• Claims Processing: Claims processing involves the actions required to pay or deny pended claims (those which did not auto-adjudicate), including: entering data into the system; reviewing and interpreting contract benefits; conducting edit and audit resolution; determining benefit eligibility; Identifying and researching processing issues through systems and manuals; routing claims to other areas; consulting internal staff and medical providers; generating correspondence; and completing forms to obtain necessary information• Knowledge/Continuous Learning: In order to perform the actions required of the Claim Specialist job, the incumbent must undergo initial training, on-the-job training, and continuing education. Demonstrating knowledge of and possessing the ability to access all relevant computer systems and screens in order to process claims accurately; staying current with continually changing processing procedures, benefits, and system modifications; being knowledgeable of and able to meet corporate and national (MTM) standards while maintaining acceptable performance levels based on established departmental standards for productivity and quality; and showing familiarity with corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks• Other duties: As assignedCertificationsHiring Range$19.77 - $25.68Security RequirementsThis position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.Segregation of DutiesSegregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.Employment TypeRegularADA Requirements1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.