Claims Specialist I

Arkansas Blue Cross and Blue Shield; Little Rock (AR); Remote; USD 42,000 - 64,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking a Claims Specialist to resolve medical claims not automatically adjudicated, ensuring quality and timely processing. The role involves investigating information, communicating with providers, and managing workload during peak periods.

The position requires a high school diploma, with additional coursework or related experience in medical terminology, anatomy, or health insurance. Remote work is available for residents in several states.

Qualifications

• High School diploma or equivalent required.
• 2 years of college coursework or equivalent certification with emphasis in anatomy, medical terminology, math, biology, or related field OR 1 year of related office experience.

Responsibilities

• Process claims that did not auto-adjudicate, ensuring timely and accurate resolution.
• Review contracts and benefits to determine eligibility and resolve processing issues.
• Generate correspondence and complete forms to obtain necessary information.

Skills

Oral & Written Communications

Interpersonal communication

Detail-Oriented

Decision Making

Teamwork

Dependability

Time Management

Researching

Reading Comprehension

Education

High School diploma or equivalent

2 years college coursework or related cert

Job description

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.

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

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

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.