Claims Examiner

Position Description

This position is responsible for the coding and total processing of claims and triaging claim adjustments generated by our providers and subscribers or requested via Customer Service, for all lines of business. Processes claims utilizing established policies and procedures to review and correct error and warning messages. Research claims and ensures proper adjudication.

Responsibilities And Qualifications

Duties and Responsibilities:

• Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors.
• Reviews and corrects on-line edit errors by interpreting generated warning messages.
• Uses appropriate systems to research and accurately process claims. Researches appropriate reference documents and imaged claims to make coding and payment decisions.
• Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions.
• May identify and report possible system or Image problems to CPR or Supervisor so that corrective action may be taken.
• All other duties and assignments as directed.
  
  

Skills

• Ability to communicate effectively and professionally with personnel, in both written and verbal form.
• Must possess a strong attention to detail and an interest in preventing errors
• Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, and etc.) as well as possess excellent keyboarding skills
• Demonstrate ability to be dependable and professional.
• Demonstrate intrinsic initiative and time management skills
• Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed
• Ability to accept feedback, learn, and adapt from guidance to be successful
• Ability to adapt to constant changing priorities and keeping daily responsibilities on task
• Ability to manage workload and ensure all tasks are completed within established timeframes
• Must be willing and able to work possible mandatory overtime as needed based on business needs
• Must be able to meet quality, productivity, and behavior expectations
• Must possess basic reading and arithmetic skills (reading and math comprehension)
  
  

Knowledge

• Preferred familiarity with provider billing documents (including in/out of state hospitals doctor, pharmacy, and suppliers) in order to code and enter appropriate data from each bill.
• Preferred familiar with medical terminology in order to correctly code and enter the appropriate ICD-10CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code.
• Preferred knowledge of both manual and automated aspects of claims processing and Image systems.
• Preferred knowledge of claims payment policies and benefits.
• Preferred competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.)
  
  

Experience

• Preferred FACETS claims Coding
• Preferred Facets claims processing
• Preferred WorkDesk Imaging
• Preferred Facets Customer Service Application
  
  

Education And Certifications

• Must have a high school diploma or GED.
  
  

Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.