Summary
 

This position completes research efficiently and accurately to ensure the departmental goals to prevent aging of claims and erroneous disbursements or claims from processing incorrectly. This position also assists in any special projects that may arise.

Description
 

40% Verify disbursement requests to ensure the request is valid and appropriately documented. Research rejected, transition, and paid status claims for validity and escalate as appropriate. Use the various systems of the department/company to complete research and gain sufficient knowledge of the claims system and how it relates to other systems.

20% May research claims to identify or validate fraud, waste or abuse.

20% Monitor inventory reports to ensure claims are resolved accordingly. Provide documentation as requested for audit purposes. May provide written or telephone correspondence to resolve claims issues.

20% Research claims as related to billing or crediting groups. Research claims to ensure the proper adjustments are made and groups receive credit or are billed appropriately.

Required Education: High School Diploma or equivalent

Required Work Experience: 3 years of experience processing claims in a healthcare environment. 2 years of experience with claims systems (can be concurrent). Division 6B - Experience must be in a Retail Pharmacy. Previous experience working with pharmacy processing claims systems is preferred.

Required Skills and Abilities: In-depth knowledge of claims payment policies and refund policies. Knowledge of related claims software systems. Knowledge of medical terminology, CPT IV coding, ICD 9 diagnosis codes, or NCPDP coding as appropriate. Good analytical skills and the ability to retrieve and research automated reports. Good time management skills and adaptable to change. Good communication skills, both written and verbal.

Required Software and Other Tools: Standard office equipment.

Required Licenses and Certificates: Division 6B - Either State or Nationally Certified Pharmacy Technician (CPhT)

Preferred Education: Bachelor's degree-in Business, Computer Science, Healthcare Administration, or a related field.

Preferred Work Experience: 4 years-of related experience if lacking degree.

Preferred Skills and Abilities: Knowledge of processing systems - RMMS, CES, AMMS, ITS, SOND, INFO, third party recovery display, and ALGS. Excellent written and verbal communication skills. Knowledge of electronic data processing systems and procedures and their integration with the users. Ability to run reports using pre-set data retrieval applications, such as DB2 and EZTRIEVE Plus, to obtain information for research and analysis.

Work Environment: Typical office environment.

 

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Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.