Claims Specialist

1400 Baltimore, Kansas City, MO 64105

Full time

R6929

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 health insurance claims of a highly complicated nature. Interprets contract information and communicates with outside parties to obtain information and coordinate coverage. Performs research and adjustments on complex claims. Able to perform audit functions for line-of-business reviews.

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 multiple claim types.

• Performs in-depth research and adjustment functions for complex claims.

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

• Exemplifies professionalism by effectively composing and responding to phone and/or written inquiries from internal and external customers as business needs dictate.

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

• Mentors other Claims Examiners and is viewed as an expert for adjustments

• Enters record of inquiries and related correspondence in computerized tracking system.

• Researches applicable medical policy and corporate, divisional, and department policies and procedures

• Maintains confidentiality of all regulated information in compliance with state and federal laws.

• Recognizes trends or common issues and raises to leadership as necessary. Provides solution options as appropriate.

• Recognizes and uses time management techniques appropriately to manage competing projects and priorities to meet customer needs and deliver on commitments in a timely manner.

• 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).

• Minimum 1 year experience as a Blue KC Claim Examiner or Customer Advocate

• Advanced Keyboarding Knowledge

• Intermediate knowledge of Microsoft Office

• Advanced knowledge of computerized claims tracking system

• Successful completion of training for Customer Service and Research and Adjustment functions.

Preferred Qualifications

• Associate’s Degree from college or technical school

• Basic understanding of Facets

• Medical terminology and ICD/CPT coding knowledge is preferred. (Level 1)

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)