Claims Specialist I

Louisiana Health Service & Indemnity Company; United States; On-site; USD 42,000 - 56,000; Full time

Job summary

Louisiana Blue is seeking a Claims Specialist I to support the claims unit. Responsibilities include accurate processing of claims edits, determining primacy for COB, and recovering funds on overpaid claims. The role does not involve people management and reports to Supervisor, Claims Operations.

Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without sponsorship. BCBSLA training or COB experience is valued.

Qualifications

• Education: High School Diploma or equivalent.
• Six months of medical claims or health insurance customer service experience or completion of BCBSLA adjustment or COB training.
• Certification in Medical Billing or Coding can be used in lieu of experience.
• BCBSLA adjustment or COB training is preferred.

Responsibilities

• Reviews and updates claims, including recalculation of benefits and processing of edits or refund requests.
• Identifies denial codes and processing codes for coordinated and non-coordinated claims.
• Determines coordination of benefits (COB) with other plans and makes necessary corrections to COB records.
• Requests medical records when required to support claim processing.
• Communicates with internal and external contacts to establish accurate claim records.
• Reviews quality audits and routes corrections within 48 hours.
• Researches order of benefits and ensures Medicare primacy is correctly applied; notifies relevant departments.
• Assists in training, implementations, and documentation as needed.
• Work is performed in a normal office environment.

Skills

Analytical ability

Oral communication

Written communication

Interpersonal skills

Education

High School Diploma or equivalent

Certification in Medical Billing or Coding

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 PURPOSE

Duties 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 SCOPE

This role does not manage people

This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS

Necessary 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.

QUALIFICATIONS

Education High School Diploma or equivalent required

Work Experience 6 months of experience in medical claims or health insurance-related customer service or the successful completion of BCBSLA adjustment or COB training

Skills and Abilities Strong analytical ability, oral and written communication skills and human relations skills are necessary.

Working knowledge of relevant PC software.

Licenses and Certifications Certification in Medical Billing or Coding can be used in lieu of experience.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

Reviews, 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 Functions

The 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 functions Perform 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 Employer

Additional Information

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