Sr Claims Specialist

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

Responsible for accurate and timely handling of claim issues for FEP. Applies and maintains comprehensive knowledge of claims processing and support systems. Provides expertise and shares knowledge to support other team members.

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.

Qualifications

Education

• High School graduate or equivalent work experience.

Experience

• 3 – 5 proven work experience in a production environment.

Knowledge, Skills, Abilities

• Demonstrated math and comprehension skills required.
• Good interpersonal skills for handling internal and external customers.
• Well-developed listening, verbal and written communication skills.
• Proficiency with Microsoft Office, specifically Excel and Word is required.
• Ability to research and investigate information using multiple sources, operating systems and documented guidelines.
• Knowledge of claims processing systems (membership, provider, adjustments)
• Experience working with providers and members preferred
• Ability to accurately perform research analysis, determine root cause and determine appropriate action
• Must have strong organizational skills and problem-solving ability.
• Must be detail-oriented

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com . We’re revolutionizing health care, and our focus is on you!

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.