Claims Examiner II

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid options, and 100% remote. If choosing to work remote, this role can be located in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

Adjudication of healthcare claims utilizing employer and payer specific policies and procedures. Responsible for reviewing the data in the claims processing system and compare with corresponding CMS and billing guidelines. Responsible for reviewing medical claims attachments when necessary to determine if services rendered was medically appropriate and benefit coverage criteria has been met. Responsible for reviewing adjudication software system's claim and line item edits for determination of whether to pay claim/line item(s). May forward claims to specialized internal and external resources. Corresponds with other departments as necessary to process claims. Accountable to performance metric scorecards. Provide guidance to less experienced claims examiners.

What you'll do:

Responsible for interpreting claim adjudication rules to process and/or adjust complex claims. Daily accountability for meeting production and quality standards by performing the following:

• Analyze claims for accuracy and completeness to determine benefits based on specific member and provider contracts, payment rules, eligibility status, COB requirements and provider status in a timely manner.
• Efficiently use multiple systems and screens to obtain and record claim information.
• Follow all relevant policies and procedures.
• Review medical record documentation, authorization information and member benefit coverage to determine the extent of liability for payment.
• Process claims within quality and production standards.
• Make determinations on the appropriate adjudication of complex claims independently.
• Review claim disputes submitted by member and providers to include urgent internal department requests.
• Take initiative and learn to assist other lines of business for Claims Examiner I level work.
• Identify areas of concern that may compromise member, provider and group satisfaction.
• Identify claims that suggest a potential issue or problem with the claim system configuration or provider contract configuration.
• Communicate any issues as appropriate for research and correction.
• Provide feedback to ensure identification of quality trends and opportunities.
• Work collaboratively with teammates within the department and with all other business partners to achieve productivity standards and adhere to accuracy standards through process improvements.
• Participate in special projects, as needed.
• Provide ideas and suggestions to ensure member and provider satisfaction.
• Partner with less experienced associates to improve the overall knowledge and performance of the team and the division as a whole.
• Promote teamwork.
• All other duties as assigned by Claims Leadership.

To be considered for this position, you must have:

• High School degree.
• Proficiency as a Claims Examiner I or relevant healthcare experience.
• Excellent verbal and written communication skills.
• Proficiency with MS Office applications.
• Team collaborator.
• Must be able to work with minimal supervision.
• Creative thinker with good problem resolution skills related to the healthcare claim adjudication.
• Strong work ethic with ability to multi-task when needed.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.