Position Description:

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Claims Processing Representative reviews and responds to technical questions from examiners in their unit. The representative is responsible for the independent research necessary to determine the correct application of benefits and maximum limitations, notifying the appropriate personnel regarding the status of inquiries, identifying and actively participating in the resolution of claims processing problems, supporting management by assuming a leadership role, assisting personnel in meeting departmental goals of timely and accurate claims/inquiries processing and providing on the job training assistance.

Responsibilities and Qualifications:

Duties and Responsibilities:

• 25% - Answer both routine and complex questions for unit personnel. and other Claims Units, Customer Service, PSTU, Clinical and other areas of the company while maintaining a level of approachability and confidentiality.
• 15% - Researches and/or processes claims in pends/queues including (but not limited to), Managed Care, ASH, CBC Employee, Priority, ITS, FEP and unique claim situations according to current and/or prior contract specifications using the Facets and Image systems. Research, maintain, and verify various on-line files and/or external applications to ensure accurate and thorough processing. Record and follow-up on all inquiries to ensure timely and accurate processing. Also, provide feedback on claim adjudication.
• 15% - Provide on the job training assistance for unit personnel with an emphasis on specific pend and warning messages, but must also be proficient in general coding and suspense procedures. Also conduct continuing training for experienced employees and provide one-on-one assistance as needed. Identify training needs and suggest action for both individuals as well as the unit.
• 15% - Assist the supervisor in developing and distributing informational bulletins, manual updates, and additional training materials to the unit to keep them up to date on system and procedural changes. Enhance and initiate updates to the online Facets processing manual.
• 10% - Identify, analyze, and document processing problems and trends in errors/questions to assist the staff in meeting the office average in productivity and accuracy. Make recommendations or initiate changes for improving operations to unit management as appropriate.
• 10% - Coordinate daily work distribution and relevant SSAE16 documentation. Maintain a current inventory of the unit’s work by researching system-generated reports and taking appropriate action to resolve any aged claims as assigned. Prepare various daily, weekly and monthly reports as assigned by the supervisor.
• 5% - %) Contact providers and other areas of the company such as Account Administration, FBS, Customer Service, Clinical Management, Provider Network, and Quality Assurance and Adjustments by telephone, e-mail, or fax to obtain information necessary for processing.
• 5% - Perform special assignments as assigned by management as well as act in support of management. This includes acting as back-up in the absence of management and the ability to make decisions independently with the right amount of risk.

*Candidates that reside within 50 miles of Harrisburg, PA preferred*

Skills:

• Ability to communicate timely and accurately in a professional and effective manner both written and verbal, with internal and external personnel at all levels while bolstering teamwork.
• Ability to easily learn new tasks and conduct focused one-on-one training sessions using effective oral, written, technical, and visual communications skills. Ability to attend or facilitate and schedule meetings to accomplish task as needed.
• Ability to document step-by-step, detailed procedures that can be easily read, understood, and followed by all users.
• Ability to effectively organize, prioritize and complete work assignments with minimal direction within the required project deadlines and timeframes.

Knowledge:

• Extensive knowledge of Facets processing guidelines and procedures for Coding, Suspense, and Special Process
• Knowledge of all types of industry standard billing formats, such as: Claim Forms, EDI Submissions, Explanation of Benefits, etc.
• Knowledge and experience in the operation of a PC and various software packages for word processing, Excel and reporting as well as both the Facets and Image systems. (i.e. using various Microsoft software packages as well as usage of Facets and Image software systems).
• Comprehensive knowledge of the Plan’s benefit programs including: Indemnity, PPO, Point of Service, HMO, Medicare Advantage HMO and PPO and Medicare Supplemental Products.
• Knowledge of all types of industry standard billing formats, such as: Claim Forms, EDI Submissions, Explanation of Benefits, etc
• Knowledge of functions performed in other departments of the plan (e.g., Account Administration, Clinical Management, Customer Service, and Provider Network)

Experience:

• 3 years claims processing experience.

Education and Certifications:

• Must have a high school diploma or GED.

Physical Demands:

Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

About Us: We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.