CareFirst Careers

Claims Processor III

Resp & Qualifications

PRINCIPAL ACCOUNTABILITIES:
Under the direction of the Manager/Supervisor, the essential duties and responsibilities include, but are not limited to, the following:

  • Uses expert knowledge of claims processing to examine all types of claims and identify key elements and processing requirements based on diagnosis, provider, paykey, medical policy, contracts, and policies and procedures.  Efficiently and accurately processes all types of claims, including catastrophic and highly complex claims, utilizing broad based product or system knowledge to ensure timely payments are generated.  Calculates deductibles and maximums, as well as researches and resolves system pends.  Works with other departments, such as Medical Review, to complete claims processing.
  • Processes all dollar volume levels of claims adjustments in accordance with policies and procedures to resolve over and underpayments.
  • Assists Customer Service Reps by providing feedback and resolving issues and answering claims processing questions.
  • Provides leadership to less experienced staff through a mentoring or buddy system.  Can Assist in training classes.
  • Gathers productivity data and compiles weekly and monthly reports on own performance.  Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning, etc.


SUPERVISORY RESPONSIBILITY:  May act in a leadership role for less experienced Claims Processors.  Can assist in training classes.

SCOPE DATA:  Handles catastrophic and highly complex claims, as well as non-standard processing.  Audits work of other Claims Processors for quality assurance.  Makes claims adjustments for all dollar volumes.  Utilizes broad based product or system knowledge.

QUALIFICATION REQUIREMENTS:

Required: 
High school degree plus 3+ years of claims experience for internal hires, or equivalent internal/external experience for external hires.

Abilities/Skills:  Demonstrated mathematical, data entry/PC, stress management, and organizational skills.  Reasoning ability, teamwork, and customer service also required.  Strong written/oral communication skills.  Advanced problem solving skills.

Preferred:  Billing or medical terminology experience.

 

Department

Department: NASCO Claims - Cumberland

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 6/17/21

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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