This position is responsible for the total processing of Facets claims, COB, adjustments, and refunds for members of the Federal Employees Program (FEP).
The incumbent is responsible for reviewing and processing Facets and FEP Direct claims that are in a pended status through interpretation of warning and error messages and instructions in accordance with processing procedures.
FEP policies and current contract specifications regarding coverage, contract limitations, and exceptions. The duties also include processing claim adjustments generated by our providers and subscribers.
The incumbent adjudicates adjustments via Facets and FEP Direct, applying thorough research techniques for correct claim adjudication.
In addition, effective communication with other Plans and Capital BlueCross Providers is required to resolve claims investigations and / or issues.
The position works collaboratively to ensure FEP Performance Measures are met.
Answer both routine and complex questions for unit personnel. and other Claims Units, Customer Service, PSTU, Clinical and other areas of the company while maintaining a level of approachability and confidentiality.
Researches and / or processes claims in pends / queues including (but not limited to) FEP and unique claim situations according to current and / or prior contract specifications using the Facets, FEP Direct and Image systems.
Research, maintain, and verify various on-line files and / or external applications to ensure accurate and thorough processing.
Record and follow-up on all inquiries to ensure timely and accurate processing.Also, provide feedback on claim
Provide on the job training assistance for unit personnel with an emphasis on specific pend and warning messages, but must also be proficient in general coding and suspense procedures.
Also conduct continuing training for experienced employees and provide one-on-one assistance as needed. Identify training needs and suggest action for both individuals as well as the unit.
Assist the supervisor in developing and distributing informational bulletins, manual updates, and additional training materials to the unit to keep them up to date on system and procedural changes.
Enhance and initiate updates to the online Facets processing manual.
Identify, analyze, and document processing problems and trends in errors / questions to assist the staff in meeting the office average in productivity and accuracy.
Make recommendations or initiate changes for improving operations to unit management as appropriate.
Coordinate daily work distribution and relevant SSAE16 documentation. Maintain a current inventory of the unit’s work by researching system-generated reports and taking appropriate action to resolve any aged claims as assigned.
Prepare various daily, weekly and monthly reports as assigned by the supervisor.
Perform special assignments as assigned by management as well as act in support of management. This includes acting as back-up in the absence of management and the ability to make decisions independently with the right amount of risk.
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.