Claims Specialist I

Arkansas Blue Cross and Blue Shield; Little Rock (AR); Remote; USD 27,000 - 35,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking a Claims Specialist to resolve medical claims not automatically adjudicated by our processing system. You will work to complete claims accurately and timely, perform investigation when needed, and communicate with providers to obtain necessary information.

The role is remote with preference for candidates in Arkansas and nearby states. Requirements include a high school diploma and at least one year of related office experience or two years of

Qualifications

• High School diploma or equivalent.
• Two years college coursework (48 semester hours) or related certification with emphasis in anatomy, medical terminology, math, biology, or a related field; OR one year of related office experience.
• Must pass company proficiency test: Claims Assessment

Responsibilities

• Claims Processing: enter data, review contracts, resolve edits, determine benefit eligibility, research issues, route claims to other areas, and generate correspondence.
• Support continuous learning: undergo training, access relevant systems, and stay current with processing procedures and standards.
• Other duties as assigned

Skills

Oral & Written Communications

Strong Interpersonal skills

Sound Judgement

Decision Making

Detail-Oriented

Teamwork

Dependability

Clinical Judgment

Time Management

Education

High School diploma or equivalent

Two years college coursework (48 semester hours) or related certification in anatomy/medical terminology/math/biology

One year of related office experience (claims processing/health insurance/medical office)

Must pass Claims Assessment proficiency test

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

This role is 100% remote. 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

Hiring Range

$19.77 - $25.68

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.