Health Insurance Claims Specialist I (COB & Edits)

Louisiana Blue; Baton Rouge (LA); Sur place; USD 42 000 - 60 000; Plein temps

Résumé du poste

Louisiana Blue is seeking a Claims Specialist I to support the claims unit with accurate processing of edits, primacy determinations for COB, and recovery of overpayments. You will ensure compliance with applicable laws and regulations and collaborate across departments.

This role does not manage people and reports to the SUPERVISOR, CLAIMS OPERATIONS. Residency in Louisiana is preferred and experience in medical claims or health insurance customer service is required or completed BCBSLA

Qualifications

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

Responsabilités

• Reviews, researches, and makes necessary updates to claims that may include: 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).

Connaissances

Analytical skills

Communication skills

Formation

High School Diploma or equivalent

Description du poste

Louisiana Blue is seeking a Claims Specialist I to support the claims unit with accurate processing of edits, primacy determinations for COB, and recovery of overpayments. You will ensure compliance with applicable laws and regulations and collaborate across departments.

This role does not manage people and reports to the SUPERVISOR, CLAIMS OPERATIONS. Residency in Louisiana is preferred and experience in medical claims or health insurance customer service is required or completed BCBSLA