Claims Specialist III

Duties may include the following responsibilities or functions required to support the claims unit. Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims. Analyzing, investigating, and resolving problem cases; executing recovery processes; and completing special projects. Assisting with developing, documenting, and testing system changes; assisting Supervisor with job training and answering staff questions. May provide direct support for Customer Service for complex issues. Responsible for accurate and timely processing of complex regular adjustment requests (Escalated Cases including those from Customer Service, Special Projects, Fraud Cases, Reconsideration/Appeal Cases, Audit Cases, DOI Cases, Presidential Cases, etc.) to ensure all contractual obligations and the highest level of member/provider satisfaction are met. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS
• Necessary Contacts: In order to effectively fulfill this position, the Claims Specialist III must be in contact with personnel in other Units: Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Enrollment and Billing, Administrative Services, and District Offices. Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans.

• High School Diploma or equivalent required

• 4 years of experience in Coordinator of Benefits (COB) or adjustments/refunds processing required
• Self-funded processing experience preferred

• Strong analytical ability, that includes strong logical, systemic, and investigates thinking.
• Excellent oral and written communication skills and interpersonal skills are necessary to handle numerous inquiries in a diplomatic manner.
• Working knowledge of relevant PC software.
• Full understanding of claims procedures, primacy rules, and claims processing guidelines are necessary.
• Strong background in claims coding, processing, edits, and adjusting payments.
• Ability to prioritize multiple streams of work effectively.

• None Required

• Reviews, researches, and makes necessary updates to claims that may include the following: 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.
• Analyzes, investigates, resolves problem cases (to include COB records, adjusting previously processed claims and requesting refund of overpaid claims). Reviews all previously processed claims to ensure consistency in payments to maximize recovery of overpayments following corporate and departmental guidelines to ensure financial stability.
• Executes procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred to ensure accuracy of claims processing and financial stability.
• Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation).
• May complete special projects as assigned by Management due to internal audit findings, multiple provider status changes, and system errors following corporate and departmental guidelines to ensure financial stability and customer satisfaction.
• Responsible for assisting with developing, documenting, testing, and approving system changes to ensure processing accuracy and prevention of unintended downstream impacts.
• Responsible for accurate and timely processing of complex claims and/or adjustments (e.g., Escalated Cases including those from Customer Service, groups, other Blue Cross plans, etc., Special Projects, Fraud Cases, Reconsideration/Appeal Cases, Audit Cases, DOI Cases, Presidential Cases, High Dollar, Benefit Management Decision (BMD), etc.) to ensure all contractual obligations are met with the highest level of member/provider satisfaction. Contacts providers, members, and internal stakeholders directly to finalize claims processing.
• Assists the supervisor with on the job training for new staff and provides support for existing staff. Interacts directly with the staff when the supervisor is unavailable. Serves as a subject matter expert of the processes and procedures in the unit, which includes, but is not limited to, validating process and procedural documentation. Serves as an active member of project teams, workgroups, and operational forums when necessary.
• Reviews audits (internal and external) and respond to all error reporting within specified deadlines following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.