Capital Blue Cross · 4 hours ago

Prepay Claims Review Specialist

Harrisburg, PA

Full-time

Remote

Mid Level

3+ years exp

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Responsibilities

Review pended medical claims to ensure accuracy of coding, billing, and supporting documentation. Verify compliance with contract terms, provider agreements, and applicable regulations. Identify discrepancies, billing errors, or potential fraud and escalate as necessary to SIU investigator. Determine if claim and accompanying documentation require medical director review to determine medical necessity of services/procedures. Manage the processing control agent process to support flagging claims for identified providers and members that are under investigative review.

Ensure adherence to federal, state, and local healthcare laws, including CMS regulations and ICD-10/CPT/HCPCS coding standards. Ensure compliance with Capital Blue Cross policies and procedures. Stay current on regulatory updates and payer-specific policies.

Work closely with internal teams, including medical directors, compliance team, provider engagement consultants, provider contracting, utilization management and claims processors, to resolve complex issues. Communicate with providers to request additional documentation or clarify billing inquiries.

Maintain accurate documentation within SIU case tracking system and Utilization Management authorization system of claim reviews, findings, and actions taken. As requested, generate and analyze reports on claim trends, common errors, and operational insights for process improvement.

Recommend updates to policies, procedures, and systems to enhance claim processing efficiency and accuracy. Participate in training sessions and contribute to cross-departmental initiatives.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Claims management systemsICD-10 codingCPT codingHCPCS codingMedical terminologyHealthcare softwareMicrosoft WordMicrosoft ExcelClaims processing experienceMedical billing experienceHealth insurance operationsPrepay claim reviewsPost-pay claim reviewsCPC certificationTime-management skills

Required

3 years of experience in claims processing, medical billing, or health insurance operations

High school diploma or equivalent required

Proficiency in claims management systems and healthcare software

Proficiency in Microsoft Office products specifically Word and Excel with the ability to use basic Excel analytic functionality (Pivot tables, Formulas, Filters etc.)

Excellent analytical, organizational, and time-management skills

Effective written and verbal communication skills for interaction with team members, providers, and leadership

Ability to work independently and maintain confidentiality of sensitive information

Strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance billing practices

Certified Professional Coder (CPC) designation or must successfully complete CPC designation within 18 months of hire