Claims Examiner I ITS

This position is responsible for the total processing of Facets claims, COB, adjustments, and refunds for members of other Blue Cross plans who receive services from our local providers and for Capital BlueCross members who receive services from out-of-area providers. The incumbent is responsible for reviewing and processing Facets claims that are in a pended status through interpretation of warning and error messages and instructions in accordance with processing procedures, Facets policies and current contract specifications regarding coverage, contract limitations, and exceptions. The duties also include processing claim adjustments generated by our providers and subscribers or requested via BlueSquared from the Host Plans for all lines of business. The incumbent adjudicates adjustments via Facets and BlueSquared, 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. Duties and Responsibilities: (30%) Adjudicates all incoming BlueCard claims by accessing the Facets System performing these major functions: Codes and enters paper claims in Facets according to policies / procedures specified in procedure manual. (Host BlueCard only), Reviews and corrects on-line edit errors by interpreting certain warning messages generated and displayed in the Facets system, Uses appropriate Facets claims applications and peripheral systems to research information to accurately process claims, Researches appropriate reference documents and Image claims to make coding and payment decisions, Handles all BlueSquared transactions, inclusive of Correspondence, Medical Record and Plan to Plan inquiries. Communicates via telephone and/or BlueSquared with other Blue Plans as well as out-of-area providers to resolve problem claim issues. Identifies and reports possible system or Image problems to Supervisor so that corrective action may be taken. Completes requests for expedites related to Plan to Plan escalations, appeal requests or in accordance with the BlueCard Default Claims Resolution. Corrects invalid SF, DF or RF records. Processes refunds from providers and CDR Associates via the Refund Information System (RIS) and coordinates all activities with the Accounting Department. Analyzes inquiries & BlueSquared communications regarding adjustments to ensure the adjustment request is valid. Ensure that all phases of the ITS processing cycles occur accurately and promptly so that claims, adjustments, misroutes and BlueSquared inquiries are processed within the timeframes established by the BCBSA and in accordance with the Inter Plan Performance (IPP) Scorecard. Skills: Ability to communicate effectively and professionally with providers and personnel at other Plans, in both written and verbal form. Ability to prioritize and initiate daily follow up of BlueSquared ‘In Box’ receipts, on-going follow up with set aside claims and inquiries as well as claim assigned inventory. Must possess the ability to operate a personal computer as well as knowledge of Windows and Image System. Ability to recognize specific claim types such as Subrogation, COB and Medicare. Knowledge: Knowledge of BlueCard, Adjustments and BlueSquared processing is preferred. Familiar with provider billing documents (including in/out of state hospitals doctor, pharmacy, and suppliers) in order to code and enter appropriate data from each bill. Familiar with medical terminology in order to correctly code and enter the appropriate ICD-9CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code. Knowledge of both manual and automated aspects of the Facets and Image systems. Knowledge of Facets claims payment policies and benefits provided under the various CBC policies. Knowledge of functions performed in other departments of the Plan. Responsible for the total processing of claims which are complex and classified as “priorities” within the department. Demonstrated ability to adapt to changing business needs and work successfully as part of a team to meet ongoing business initiatives. Experience: Must have prior experience with processing Facets claims. Education and Certifications: A high school diploma or GED. Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield 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. Capital Blue Cross has built a reputation as being “more than” a health insurance company. We are an industry and community leader that understands the foundation of our success is serving people—addressing their needs, guiding them through their health and wellness journey, exceeding their expectations, and giving back to the communities we serve. We could not accomplish these goals without our employees, which is why we work so hard to provide a positive, supporting culture that encourages and rewards excellence. Capital Blue Cross offers competitive pay, bonus opportunities, quality benefits, health and wellness incentives, and opportunities for career advancement and community involvement. Our positive workplace culture and employee involvement in our communities have earned us recognition as one of The Best Places to Work in PA and Corporate Citizen of the Year. The success of our company relates directly to the efforts of our dedicated workforce made up of talented individuals, who understand that a career at Capital Blue Cross is “more than” simply a job. To experience that kind of opportunity, consider applying to join our fearless team. As a federal contractor, employees of Capital Blue Cross are required to be fully vaccinated against COVID-19 unless approved for a medical or sincerely held religious belief exemption. Please ask your recruiter for more information.