Claims Specialist

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Accurately process claims edits.

• Establish primacy for Coordination of Benefits (COB).

• Modify claims that have been previously paid.

• Initiate actions to recover funds from claims that have been overpaid.

• Review, research, and update claims, including recalculating benefits, processing claims edits, and managing refund requests.

• Implement contractual benefits and provider reimbursement policies.

• Recognize denial codes, edits, and processing codes to accurately handle both coordinated and non-coordinated claims.

• Request medical records as needed.

• Engage with internal and external parties to ensure accurate claim record maintenance.

• Evaluate quality audits and rectify or escalate them within 48 hours.

• Investigate and establish the proper order of benefits, making necessary COB record adjustments.

• Notify the relevant department of any discrepancies in Medicare primacy and ensure the generation of notification letters.

• Support training, implementation, documentation, and other assigned tasks.

• Report directly to the Supervisor of Claims Operations.

• Collaborate with various stakeholders, including internal departments, providers, members, attorneys, groups, insurers, and other plans.

⛳️ Requirements

• A High School Diploma or equivalent is required.

• Minimum of 6 months of experience in medical claims or health insurance-related customer service, or completion of BCBSLA adjustment or COB training.

• Certification in Medical Billing or Coding may substitute for experience.

• Strong analytical skills are essential.

• Proficient oral and written communication abilities.

• Excellent human relations skills.

• Familiarity with relevant PC software is required.

• Must be authorized to work for Louisiana Blue in the United States without needing employer-sponsored immigration support.

• Must not require current or future employment-based immigration sponsorship or employer assistance.

• Successful completion of pre-employment drug screening is mandatory.

• Felony convictions involving dishonesty or breach of trust necessitate written consent from the state insurance commissioner to work in the insurance industry.

🏝️ Benefits

• Access to resources for living well and maintaining health.

• Opportunities for learning and professional development.

• Skills enhancement and career growth potential.

• Opportunities to contribute to local communities.

• Reasonable accommodations available for individuals with disabilities.

• A smoke- and tobacco-free workplace.

• Background checks and pre-employment drug screenings.

• A drug-free workplace environment.