Claims Examiner I

Work At Home - Missouri

Full time

R6926

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:

Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

Annual incentive bonus plan based on company achievement of goals

Time away from work including paid holidays, paid time off and volunteer time off

Professional development courses, mentorship opportunities, and tuition reimbursement program

Paid parental leave and adoption leave with adoption financial assistance

Employee discount program

Job Description Summary:

Under general supervision, assesses claim information, references contracts and performs calculations and other functions to accomplish the processing and payment of insurance claims of a complicated or non-routine nature. Interprets contract information and communicates with outside parties to obtain information and coordinate coverage. Performs claim research and adjustments.

Job Description

EACH DUTY AND RESPONSIBILITY MUST BE PERFORMED IN ACCORDANCE WITH INDIVIDUAL PERFORMANCE SCORECARD PRODUCTION AND QUALITY STANDARDS.

• Successfully completes all training programs as required for the level.

• Processes claims for two products or claim types (dental, hospital, medical, ITS, FEP).

• Performs research and adjustment functions for claims.

• Perform special projects (e.g., complex accumulator reconsiderations, New Directions).

• Responds to written inquiries from internal and external customers as business needs dictate.

• Sets up deducts, CLOV table entries, and other assigned finance functions.

• For FEP positions, processes all deferrals for FEP or edit corrections in computerized claims system.

• Performs complex FEP transactions (e.g., FEP Direct DDE, FEP Retro-enrollment, Out of Balance) and member appeals.

Minimum Qualifications

• High school diploma or general education degree (GED).

• 2 years of previous customer service, member services, or claims processing experience; or any combination of required education and experience.

• Advanced Keyboarding Knowledge

• Intermediate knowledge of Microsoft Office

Preferred Qualifications

• Knowledge of FACETS and/or other computerized claims processing system as applicable (FEP).

• Associates degree from college or technical school

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.

At Blue Cross and Blue Shield of Kansas City (Blue KC), we have long put our members first by developing products and services to meet their needs. From our founding in 1938 to more than 80 years of experience in innovative, patient-centered healthcare coverage, Blue KC continues to keep our members at the center of everything we do. As a market leader, we continue to embrace new ideas to make healthcare more affordable and to improve the customer experience. Come join us!

Blue Cross and Blue Shield of Kansas City will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully utilize electronic and online job application systems. For assistance, please send an email to [email protected] .

EOE/Veterans/Disability

Affirmative Action Employer

E-Verify Participation (https://bluekcmemberportal.azureedge.net/pdf/2024/E-Verify\_Participation\_Poster\_Eng\_Es.pdf)

Equal Employment Opportunity/Nondiscrimination/Affirmative Action Policies

IER Right to Work (https://www.e-verify.gov/sites/default/files/everify/posters/IER\_RightToWorkPoster%20Eng\_Es.pdf)

FMLA

Employee Polygraph Protection Act (https://www.dol.gov/whd/regs/compliance/posters/eppac.pdf)