Claims Specialist I

03 HMO Partners Inc.; Arkansas; Hybrid; USD 52,000 - 70,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield seeks a Claims Specialist to resolve non-auto-adjudicated medical claims with precision. You will review contracts, determine benefits, and communicate with providers to obtain missing information.

The role supports timely, compliant processing in a remote work setting across several states. Candidates should have a high school diploma, 1–2 years of related office experience, and strong communication skills.

Qualifications

• Requires high school diploma or equivalent.
• Minimum 48 semester hours or related coursework in anatomy/medical terminology/math/biology or related field or 1 year of related office experience.
• Must pass proficiency test: Claims Assessment.

Responsibilities

• Resolve non-auto-adjudicated claims promptly and accurately.
• Review contracts, determine benefit eligibility, and research processing issues.
• Maintain knowledge of processing procedures, systems, and codebooks.

Skills

Oral communications

Written communications

Interpersonal skills

Detail oriented

Teamwork

Dependability

Critical thinking

Time management

Reading comprehension

Organizing

Process information

Evaluating information

Customer service

Clinical judgment

Education

High School diploma

48 semester hours or related coursework

Related office experience (claims processing/health insurance)

Tools

ICD codes

CPT codes

HCPCS codebooks

Job description

Job Summary

The 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 Specialist.

Requirements

EDUCATION

High School diploma or equivalent.

EXPERIENCE

Minimum 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 Assessment ESSENTIAL SKILLS & ABILITIES Oral & Written Communications Strong Interpersonal skills Sound Judgement Decision Making Detail-Oriented Teamwork Dependability

Location

Work from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference will be given to current employees and candidates who reside in Arkansas, Utah, Idaho, and North Dakota.

Skills

• Clinical Judgment
• Computer Work
• Critical Thinking
• Customer Service
• Decision Making
• Evaluating Information
• Interpersonal Communication
• Oral Communications
• Organizing
• Process Information
• Reading Comprehension
• Researching
• Time Management

Responsibilities

• 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 assigned

Certifications & Security Requirements

This 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 Duties Segregation 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 Type

Regular ADA Requirements 1.1 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.

Company Culture

Arkansas Blue Cross is consistently ranked as one of the best places to work in Central Arkansas. Why? We Love our Employees At Arkansas Blue Cross, we care about the health, wellness, and education of our employees. We offer many great incentives such as: Tuition reimbursement. Club Blue, a free, onsite gym to encourage exercise. Green Leaf Grill and Green Leaf Grill Express, onsite restaurants in Little Rock that promote healthy eating. Incentives for wellness education and exercise We Love our Culture The average tenure is 10 years with hundreds of employees having been here 15 years or longer. Our inclusive culture brings employees together to connect while celebrating our differences. We Love our Community Our employees often volunteer within their communities, at charity events, walks and runs, schools and nonprofits. When disasters strike, our employees help wherever they are needed. It’s just another way we show that Blue cares.