Claims Examiner
Capital BlueCross
hace 6 días

This position is responsible for the total processing of Facets claims, COB, adjustments, and refunds for members of other Blue Cross plans who receive services from our local providers and for Capital Blue Cross members who receive services from out-of-area providers.

The incumbent is responsible for reviewing and processing Facets claims that are in a pended status through interpretation of warning and error messages and instructions in accordance with processing procedures, Facets policies and current contract specifications regarding coverage, contract limitations, and exceptions.

The duties also include processing claim adjustments generated by our providers and subscribers or requested via BlueSquared from the Host Plans for all lines of business.

The incumbent adjudicates adjustments via Facets and BlueSquared, applying thorough research techniques for correct claim adjudication.

In addition, effective communication with other Plans and Capital Blue Cross Providers is required to resolve claims investigations and / or issues.

The position works collaboratively to ensure National Programs InterPlan Performance Measures are met.

Adjudicate all incoming BlueCard claims by accessing the Facets System performing these major functions :

  • Codes and enters paper claims in Facets according to policies / procedures specified in procedure manual. (Host BlueCard only)
  • Reviews and corrects on-line edit errors by interpreting certain warning messages generated and displayed in the Facets system.
  • Uses appropriate Facets claims applications and peripheral systems to research information to accurately process claims.
  • Researches appropriate reference documents and Image claims to make coding and payment decisions.
  • Handles all BlueSquared transactions, inclusive of Correspondence, Medical Record and Plan to Plan inquiries.
  • Communicate via telephone and / or BlueSquared with other Blue Plans as well as out-of-area providers to resolve problem claim issues.

    Identifies and reports possible system or Image problems to Supervisor so that corrective action may be taken.

    Complete requests for expedites related to Plan to Plan escalations, appeal requests or in accordance with the BlueCard Default Claims Resolution.

    Corrects invalid SF, DF or RF records.

    Process refunds from providers and CDR Associates via the Refund Information System (RIS) and coordinates all activities with the Accounting Department.

    Analyze inquiries & BlueSquared communications regarding adjustments to ensure the adjustment request is valid.

    Ensure that all phases of the ITS processing cycles occur accurately and promptly so that claims, adjustments, misroutes and BlueSquared inquiries are processed within the timeframes established by the BCBSA and in accordance with the Inter Plan Performance (IPP) Scorecard.

    Knowledge :

  • Knowledge of BlueCard, Adjustments and BlueSquared processing is preferred. Familiar with provider billing documents (including in / out of state hospitals doctor, pharmacy, and suppliers) in order to code and enter appropriate data from each bill.
  • Familiar with medical terminology in order to correctly code and enter the appropriate ICD-9CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code.
  • Knowledge of both manual and automated aspects of the Facets and Image systems. Knowledge of Facets claims payment policies and benefits provided under the various CBC policies.
  • Knowledge of functions performed in other departments of the Plan. Responsible for the total processing of claims which are complex and classified as priorities within the department.
  • Demonstrated ability to adapt to changing business needs and work successfully as part of a team to meet ongoing business initiatives.
  • Skills :

  • Ability to communicate effectively and professionally with providers and personnel at other Plans, in both written and verbal form.
  • Ability to prioritize and initiate daily follow up of BlueSquared In Box’ receipts, on-going follow up with set aside claims and inquiries as well as claim assigned inventory.
  • Must possess the ability to operate a personal computer as well as knowledge of Windows and Image System.

    Ability to recognize specific claim types such as Subrogation, COB and Medicare.

    Experience :

  • Must have prior experience with processing Facets claims.
  • Education, Certification, and Licenses :

    A high school diploma or GED.

    Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity / affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.

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