Apply on Employer Site

Louisiana Blue · 12 hours ago

Claims Specialist II

Baton Rouge, LA

Full-time

Onsite

Entry, Mid Level

2+ years exp

Louisiana Blue is dedicated to ensuring the well-being of its employees and the community. They are seeking a Claims Specialist II to accurately process claims, analyze and resolve issues, and ensure compliance with regulations while maintaining high customer satisfaction.

Health CareInsuranceNon Profit

Responsibilities

Reviews, researches, and makes necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction

Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) in order to process both coordinated and non-coordinated claims correctly. Requesting of medical records may be required

Communicates, both orally and in writing, with internal and external contacts in order to provide necessary and accurate information for the establishment of sound claim records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc

Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction

Researches, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare. Failure to report discrepancy could result in a daily fine up to $1,000.00

Analyzes, investigates, resolves problem cases (to include COB records, adjusting previously processed claims and requesting refund of overpaid claims). Reviews all previously processed claims to ensure consistency in payments to maximize recovery of overpayments following corporate and departmental guidelines to ensure financial stability

Executes procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred to ensure accuracy of claims processing and financial stability

Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation)

May complete special projects as assigned by Management due to internal audit findings, multiple provider status changes, and system errors following corporate and departmental guidelines to ensure financial stability and customer satisfaction

Qualification

Medical claims processingCoordination of Benefits (COB)Analytical abilityPC software knowledgeHuman relations skillsPrioritization skillsOral communication skillsWritten communication skills