Claims Specialist
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Job Description
Claims Specialist resolving pended medical claims for Arkansas Blue Cross and Blue Shield. Investigating benefits, eligibility, coding, audits, and processing issues remotely.
Responsibilities:
- Resolve medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner according to divisional quality and productivity standards.
- Investigate claims and communicate to obtain necessary information to complete claims.
- Enter data into the claims system.
- Review and interpret contract benefits.
- Conduct edit and audit resolution.
- Determine benefit eligibility.
- Identify and research processing issues through systems and manuals.
- Route claims to other areas.
- Consult internal staff and medical providers.
- Generate correspondence and complete forms to obtain necessary information.
- Complete initial training, on-the-job training, and continuing education.
- Access relevant computer systems and screens to process claims accurately.
- Stay current with changing processing procedures, benefits, and system modifications.
- Meet corporate and national (MTM) standards while maintaining departmental productivity and quality levels.
- Use corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks.
- Perform other duties as assigned.
Requirements:
- High School diploma or equivalent.
- Minimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field, OR minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.
- Must pass company proficiency test: Claims Assessment.
- Oral & Written Communications.
- Strong Interpersonal skills.
- Sound Judgement.
- Decision Making.
- Detail-Oriented.
- Teamwork.
- Dependability.
- Must ensure the security and confidentiality of records and information.
- Must adhere to segregation of duties guidelines in the Administrative Manual.
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