Claims Specialist I

Bcbsla; Louisiana; On-site; USD 42,000 - 70,000; Full time

Job summary

BCBSLA is seeking a Claims Specialist I to support the claims unit by processing edits, determining primacy for COB, adjusting previously paid claims and initiating overpayment recovery. The role requires attention to regulatory compliance and strong communication with internal teams and external providers.

Responsibilities include researching COB, reviewing denial codes, and ensuring accurate claim records, with emphasis on accuracy and customer satisfaction.

Qualifications

• High School Diploma or equivalent required.
• 6 months of experience in medical claims or health insurance-related customer service or completion of BCBSLA COB training.
• Strong analytical ability and good oral and written communication skills.
• Working knowledge of relevant PC software.

Responsibilities

• Recalculate benefits for previously processed claims and process edits or refunds per benefits rules.
• Identify denial codes, processing codes, and COB coordination for both coordinated and non-coordinated claims.
• Communicate with internal and external contacts to establish sound claim records.
• Review quality audits within 48 hours to ensure accuracy and customer satisfaction.
• Research order of benefits and correct COB records; notify Medicare when primacy is misapplied.
• Assist in training, implementations and documentation as needed.

Skills

Analytical ability

Oral communication

Written communication

Human relations

Education

High School Diploma or equivalent

Tools

PC software

Job description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.Residency in or relocation to Louisiana is preferred for all positions.Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.POSITION PURPOSEDuties may include the following responsibilities or functions required to support the claims unit. Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.NATURE AND SCOPEThis role does not manage peopleThis role reports to this job: SUPERVISOR, CLAIMS OPERATIONSNecessary Contacts: In order to effectively fulfill this position, the Claims Specialist I must be in contact with personnel in other Units: Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Enrollment and Billing, Administrative Services, and District Offices. Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans.QUALIFICATIONSEducationHigh School Diploma or equivalent requiredWork Experience6 months of experience in medical claims or health insurance-related customer service or the successful completion of BCBSLA adjustment or COB trainingSkills and AbilitiesStrong analytical ability, oral and written communication skills and human relations skills are necessary.Working knowledge of relevant PC software.Licenses and CertificationsCertification in Medical Billing or Coding can be used in lieu of experienceACCOUNTABILITIES AND ESSENTIAL FUNCTIONSReviews, researches, and makes necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) in order to process both coordinated and non-coordinated claims correctly. Requesting of medical records may be required.Communicates, both orally and in writing, with internal and external contacts in order to provide necessary and accurate information for the establishment of sound claim records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc.Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.Researches, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare. Failure to report discrepancy could result in a daily fine up to $1,000.00.Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation).Additional Accountabilities and Essential FunctionsThe Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functionsPerform other job-related duties as assigned, within your scope of responsibilities.Job duties are performed in a normal and clean office environment with normal noise levels.Work is predominately done while standing or sitting.The ability to comprehend, document, calculate, visualize, and analyze are required.An Equal Opportunity EmployerAll internal employees please apply through Workday Careers.PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)Additional InformationPlease be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the \"My Applications\" section in the Candidate Home section of your Workday account.If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [e-mail] for assistance.In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.