Claims Specialist II
About the position The Claims Specialist II position at Blue Cross involves supporting the claims unit by accurately processing claims edits, determining primacy for Coordination of Benefits (COB), adjusting previously paid claims, and initiating recovery procedures for overpaid claims. The role requires analyzing and resolving problem cases, executing recovery processes, and ensuring compliance with relevant laws and regulations. This position does not involve managing people and reports to the Supervisor of Claims Operations.
Responsibilities
- Accurately process claims edits and determine primacy for Coordination of Benefits (COB).
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- Adjust previously paid claims and initiate procedures to recover funds on overpaid claims.
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- Analyze, investigate, and resolve problem cases related to claims processing.
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- Execute recovery processes for overpayments to ensure financial stability.
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- Communicate with internal and external contacts to provide necessary information for claims processing.
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- Review quality audits and ensure accuracy of claims processing within departmental guidelines.
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- Research and determine the correct order of benefits for payment and make necessary corrections to COB records.
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- Assist in training, implementations, and documentation as needed.
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- Complete special projects as assigned by management.
Requirements
- High School Diploma or equivalent required.
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- 2 years of experience in medical claims processing required.
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- Strong analytical ability with logical and investigative thinking skills.
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- Strong oral and written communication skills.
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- Working knowledge of relevant PC software.
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- Ability to prioritize multiple streams of work effectively.
Nice-to-haves
- Experience in Coordination of Benefits (COB) processing preferred.
Benefits
- Health insurance coverage
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- Professional development opportunities
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- Flexible scheduling options
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- Paid holidays
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- Wellness programs
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