Claims Specialist I

Arkansas Blue Cross Blue Shield; United States; Remote; USD 42,000 - 66,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking a Claims Specialist to resolve non-auto adjudicated medical claims with precision and speed, in line with divisional standards.

The role involves data entry, benefit interpretation, and coordinating with providers to obtain missing information while maintaining service quality during peak periods and system downtime.

You will contribute to process improvements, stay current with ICD/CPT coding, and work remotely from multiple states in the U.S.

Qualifications

• High School diploma or equivalent.
• Two years of college coursework (48 sem. hrs) or related certification in anatomy, medical terminology, math, or biology.
• Or at least one year of related office experience such as claims processing, health insurance, or medical office.
• Must pass company proficiency test: Claims Assessment

Responsibilities

• Claims Processing: pay or deny pended claims, enter data, review and interpret contract benefits, conduct edit and audit resolution, determine benefit eligibility.
• Identify and research processing issues through systems and manuals; route claims to other areas; consult internal staff and medical providers; generate correspondence; complete forms to obtain necessary information.
• Other duties: As assigned

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

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

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.