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Claims Reseach Specialist/Adjustor

Employer
Blue Cross Blue Shield of ND
Location
Fargo, ND
Salary
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Job Details

The Claims Research Specialist is responsible for using knowledge to conduct research on complex claims and benefits issues and adjust appropriate claims. This role identifies trending issues within claims processing and assists with frontline resolution to ensure that questions or concerns are resolved in a timely manner. This position works directly with various internal departments and external entities to resolve questions pertaining to claims and benefits.

Essential Functions

  • Conducts in-depth research on claims and benefits issue requests received through internal systems.
  • Reviews claims errors to determine if it's a system or manual error, documents research outcomes and adjusts claims per benefits policies and procedures, if necessary.
  • Follows up with appropriate individuals or areas to gather additional information to remedy issues. Clearly documents sources and validates the accuracy of data/information to resolve inconsistencies.
  • Acts as resource and support for internal departments and management on issues involving claims and benefits.
  • Assists various departments with frontline phone inquiries in attempt to resolve questions on initial contact.
  • Identifies provider inquiry patterns and internal performance issues then communicates concerns to management and/or appropriate team.
  • Processes Medicare crossover adjustment claims and determines if adjustments are needed.
  • Researches various specialized requests for the Centers for Medicare and Medicaid Services (CMS) including but not limited to: the verification of a member's Medicare coverage, identifying and reviewing claims processed by Medicare and Blue Cross Blue Shield of North Dakota, determining appropriate payments to Medicare and processing appropriate claims, communicating with CMS to provide time-sensitive information and collaborating with external collection agencies and internal staff as needed.
  • Completes requests generated from reports and various departments in the organization resulting from systems issues, fraudulent payments or changes in processes.


Requirements

Knowledge, Skills and Abilities

Communication (Verbal/Written)

Intermediate

Attention to Detail and Accuracy

Intermediate

Customer Interaction

Basic

Task and Goal Focus

Basic

Problem Solving and Resolution

Intermediate

Education Requirements

Required: High School Diploma/GED

Preferred: High School Diploma/GED

Field(s) of Study: N/A

Experience Requirements

Required: Minimum of 1 Year

Preferred: Minimum of 1 Year

Experience Details: Minimum of 1 year of customer service, office-setting or related experience is required; claims processing experience is preferred.

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com

This job posting will be closed 2/25/2019 at 8:00AM CST. No further applications will be considered.

Company

TWO WORDS – MEMBERS FIRST.

That sums up why we’re here. And according to member satisfaction surveys, 95.6% say we’ve done a great job at maintaining that focus.

With that said, there are still mountains to move. America’s health care system needs an overhaul and Blue Cross Blue Shield of North Dakota is taking a lead role. To accomplish that, we need BOLD people who believe they can make an impact.

Are you ready to shake up an industry?

If you’re passionate about taking on our nation’s number one health care concern, there may be a place for you on one of our teams.

Company info
Website
Location
4510 13th Ave. S.
Fargo
ND
58103
United States

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