Senior Claims Specialist: Complex Adjustments & Resolution

Independence Blue Cross; Philadelphia (Philadelphia County); On-site; USD 60,000 - 90,000; Full time

Job summary

Independence Blue Cross (IBX) is seeking a claims professional to handle FEP claim issues with accuracy and timeliness. You will research and adjust complex, high-dollar adjustments and reconsiderations, ensuring compliance with manuals and guidelines.

Responsibilities include supporting multiple claim systems, responding to inquiries, detecting trends, and mentoring junior staff. Strong Excel/Word skills and detail-oriented work are required.

Qualifications

• High School graduate or equivalent work experience.
• 3–5 proven work experience in a production environment.
• Demonstrated math and comprehension skills.
• Strong interpersonal, listening, speaking and writing skills.
• Proficiency with Excel and Word.
• Ability to research information using multiple sources and guidelines.
• Knowledge of claims processing systems (membership, provider, adjustments).
• Experience with providers and members preferred.
• Strong organizational skills and detail orientation.

Responsibilities

• Research and adjust complex and/or high dollar adjustment requests received from all areas, inclusive of internal and external sources (e.g. other plans, providers, FEP Directors Office).
• Handle FEP reconsiderations accurately and timely per the FEP benefit manuals and guidelines
• Meet departmental quality and production requirements.
• Respond professionally to external/internal inquiries, as appropriate, while maintaining corporate and departmental standards.
• Research and analyze complex claims that are paid incorrectly; recover overpaid and underpaid claim dollars and ensure all necessary transactional steps are taken to accurately process claim adjustments.
• Follow departmental standard for responses to all inquiries, and ensure the standard is achieved.
• Report observed trends of continuous claim errors/problems for corrective interventions.
• Assist junior staff as needed.

Skills

Math skills

Interpersonal skills

Listening & communication

Excel & Word

Research & analysis

Claims processing knowledge

Provider/member experience

Root-cause analysis

Organization & problem solving

Attention to detail

Education

High School diploma

Tools

Microsoft Office

Job description

Independence Blue Cross (IBX) is seeking a claims professional to handle FEP claim issues with accuracy and timeliness. You will research and adjust complex, high-dollar adjustments and reconsiderations, ensuring compliance with manuals and guidelines.

Responsibilities include supporting multiple claim systems, responding to inquiries, detecting trends, and mentoring junior staff. Strong Excel/Word skills and detail-oriented work are required.