Claims Research Associate

Blue Cross Blue Shield Association • Full-time • Remote (Birmingham, AL, US) • 6d ago

Overview

Department Overview

Claims Benefit Administration (CBA) area supports the analysis, design and implementation of group benefits, the creation of Summary Plan Descriptions, the development of Blue Exchange records, the creation of Benefits Online and day-to-day involvement in the development and implementation of strategies designed to address complex processing issues through project implementation. CBA also is involved in process improvements and maintenance on behalf of the Claims Division which support our Divisional, Corporate, and Mandated initiatives. Our highly technical projects support the enhancement of critical benefit application, system corrections, mandated changes and corporate initiatives which affect global areas of Claims Processing.

Realistic Job Preview

Please view the following video for a realistic job preview of the Claims Research Associate position.

Primary Responsibilities

The primary function of the Claims Research Associate position is two–fold, consisting of medical claims processing and inquiry resolution. Each claim is processed according to business regulation, internal standards, and processing guidelines. Inquiries are resolved within accuracy and timeliness goals, specific to customer contract agreements. The Incumbent is responsible for reviewing claims for errors and comparing member benefits to services requested. The Incumbent will also perform an analysis of the claim and make necessary updates that may include recalculation of benefits for previously processed claims to determine the correct order of benefits for payment to be made by the applicable plan. It is also the responsibility of the incumbent to reject, redirect misrouted, or ask clarifying questions when information is incomplete or inaccurate to ensure timely processing as outlined by service level agreement goals. The Incumbent will be responsible for communicating via inquiry, email and telecommunication across multiple areas of the company to ensure customer resolution is complete

The Inquiry and Claims Management Solutions (ICMS) program is designed to provide a structured and engaging environment to learn all functions of the Claims Research Associate position of Blue Cross and Blue Shield of Alabama. The program is structured into three phases: training, benchmark, and fluency. The maximum duration of the program for each incumbent for phase one (classroom training) is up to 8 weeks depending on the training program; while phase two can last as long as 18 weeks (benchmark/practical application). For an associate to reach phase three training (fluency), the incumbent must meet production, timeliness and quality goals that are in place under phase two. The fluency phase will last 13 weeks. After successfully completing the three training phases, the associate is then transitioned into the Inquiry Analysis and Claims Solutions (IACS) area within the Claims division.

Phase One: Classroom Training Phase – The training program consists of computer-based course work, facilitator-led discussion and practical application. The associate must apply the training concepts appropriately and achieve an expected standard of performance during the training program. The training goals for practical application are established to assist associates in reaching the minimum established performance level of accuracy, timeliness and production for this position.

Phase Two: Benchmark Phase – Incumbent will work toward achieving actual production, quality, and timeliness goals that are currently in place in the Claims division. Associates are aggressively paced through this program by being placed on “mini-goals” each week. They currently have a maximum time of 18 weeks to achieve the actual goal of the position.

Phase Three: Fluency Phase – Incumbent has successfully “benchmarked” and is placed into the department’s fluency phase in Claims.

Summary of Qualifications

High School Diploma or equivalent
Experience interacting with customers
Experience in a position requiring problem solving and analytical skills
Experience in a position demonstrating time management and organizational skills to organize and prioritize tasks
Experience in a position demonstrating research skills to research information using a computer and/or reference materials
Willing to work set schedule
Demonstrated experience in a keying environment
Strong communication skills to interpret and communicate information both orally and written, including documenting detailed information
Bachelor’s Degree preferred
Experience in a position with production, accuracy, and/or timeliness requirements preferred
Experience adjusting and adapting to necessary changes due to business needs preferred
Claims coding and ICD knowledge preferred

*Start date will take place in March of 2025*

Work Location

The work location for this position will be full-time onsite during the training program, which consists of multiple phases. Remote/hybrid schedules can be available once all phases of training program have been completed.

Terms and Agreements

By submitting a job application, I attest that all information to the best of my knowledge is true and accurate. Furthermore, I understand that any information provided by me throughout the job application process is subject to verification including, but not limited to work experience, education, assessment (test) and interviews.
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Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association