Claims Research Associate

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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 five phases: training (Phases 1&3), benchmark(Phases 2&4), and Fluency. The maximum duration of the program for each incumbent for phase one (classroom training) is up to 13 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. Phases One and Three: Classroom Training Phases - 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. Phases Two and Four: Benchmark Phases - 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 Five: 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
• 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 April of 2024*

Work Location

The work location for this position will be hybrid (onsite/remote).

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. We appreciate your interest in Blue Cross and Blue Shield of Alabama 'The Company'. The Company does not discriminate in hiring or employment on the basis of race, color, religion, creed, sex, sexual orientation, gender identity, national origin, age, disability, genetics, status as a disabled or protected veteran, or because of citizenship status in the case of a citizen or intending citizen. No question on this application is intended to secure information to be used for such discrimination. Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association