This position is responsible for processing claims for a variety of products in an accurate and timely manner. In addition, this position generates daily reports and is responsible for other duties assigned by the supervisor. This position can progress to Claim Expert (5009) based on competencies.
Job Duties & Responsibilities
Adjudicate all claims to completion or returns to provider or member for additional or missing information
Process claims accurately and timely in support of MTM or other performance measures
Handle all claim edits appropriately including possible duplicates, eligibility status, corrected bills, manual pricing when appropriate, provider screen messages, authorizations, pre-existing condition, big bill guidelines, etc.
Administer benefits according to Benefit Summary and or Online Help (OLH) processing guidelines
If necessary, route problem claims to TTE, Supervisor, CARR, UM or Case Management, COB, Subrogation Unit, etc.
Compile processed claims in a processed folder with processor number and date in the secure paid claims department file for verification, quality and records storage when appropriate
Ensure timely and accurate completion of daily/weekly reports
Stay up-to-date regarding online resources, such as Online Help, BlueAlert, Medical Policy, and all other electronic resource changes when applicable
Keep abreast of changing divisional guidelines and government regulations
Recognize cause of problem and effect of resolution
Perform miscellaneous projects as assigned
Work overtime as required
High School Diploma or equivalent required
Claims processing and/or customer service experience preferred
If current employee with the company, must meet minimum performance expectations
Previous health care experience is preferred
Microsoft Office products knowledge desired
Effective oral communication and interpersonal skills
Good written communication skills
Sound decision-making and problem-solving skills
Exceptional organizational and time management skills
Must be able to key 6500 keystrokes per hour with less then 10% error rate
BlueCross BlueShield of Tennessee - 2 years ago
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....