Claims Examiner

Blue Cross and Blue Shield of Kansas is a trusted healthcare organization committed to the well-being of Kansans. They are seeking a Claims Examiner responsible for reviewing, evaluating, and processing health claims to ensure accuracy and compliance with regulations and guidelines.

Responsibilities

• Accurately review, analyze, and verify healthcare claims submitted by policyholders or medical providers
• Ensure all necessary documentation, coding (International Classification of Diseases, Tenth Revision (ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS)), and data are included and correct
• Check for eligibility, coverage, and applicable benefits as per policy terms
• Enter and process claims information into the system with precision and attention to detail
• Apply appropriate insurance guidelines, including deductibles, co-pays, co-insurance, and maximum coverage limits
• Approve or deny claims based on policy coverage, ensuring compliance with regulatory and company standards
• Perform adjustments to processed claims as needed for corrective action
• Correspond with healthcare providers, patients, and internal departments to clarify or resolve discrepancies
• Investigate and resolve complex or escalated claim issues, such as coding errors, benefit misunderstandings, or billing discrepancies
• Ensure compliance with state and federal healthcare regulations
• Maintain detailed and accurate records of all claims processed, including documentation for audits or reviews
• Meet individual and team performance targets related to claims processing speed, accuracy, and quality
• Participate in ongoing training to stay updated on changes in health insurance policies and claims processing technologies
• Monitor and work daily reports to ensure timely claim control

Skills

• Strong attention to detail and organizational skills
• Knowledge of medical claim processing, medical terminology, insurance policies, and coding standards (ICD, CPT)
• Excellent communication skills, both written and verbal
• Ability to work efficiently under pressure and meet deadlines
• Critical thinking and problem solving skills
• High school diploma or equivalent required
• Office and/or computer system experience preferred
• Previous experience in healthcare claims processing, medical billing, medical terminology, or health insurance is preferred

Benefits

• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

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