Non Exempt / Bargaining Unit Posting -
Local / Seniority Unit- 2145
Date Posted 10/27/21
Deadline Date- 11/3/21
Job Title BCNA Claims Liaison
Department -127200 BCN-Claims-BCNA
Salary Grade - UF - Please reference Appendix A of the BCBSM/BCN MLA
Job Code - 8010
Number of Openings - multiple
Status regular FT
Site- Grand Rapids
The BCNA Claims Liaison is responsible for the adjudication of medical and hospital claims at all pend levels, manual pricing using external pricers, addressing inquiries received from other departments, adjustment of previously paid or denied medical and hospital claims, processing checks received from providers, in accordance with CMS and other relevant regulations and corporate policies.
Responsible for the investigation and resolution of pended claims in an accurate and timely manner as required by the Center for Medicare and Medicaid Services (CMS), as well as standards imposed by BCN and BCNs key stakeholders. This requires following procedures which are difficult and may require manual pricing and use of external pricing programs.
Processes adjustments of previously processed claims to correct for processing errors, system set-up changes, new information received, COB, returned provider checks, pricing changes, benefit changes, grievance resolution, recoveries and other reasons.
Researches and responds to inquiries and adjusts claims received from other departments including Customer Service, Field Services, CPI, Provider Affairs, SIU and the BCNA Team. This research may require communication with other BCN departments and communication with BCN members and providers.
Interacts with internal departments to clarify issues and address the root causes of problems related to BCNA adjustments and claim processing activity including pricing trends and inaccuracies and provider data research for loading and correcting provider data.
Perform other reasonably related duties, including special projects as assigned by immediate supervisor and other management staff as required.
High school diploma or GED required.
Associates Degree or additional college credits preferred.
ICD-10 and CPT-4 continuing education course(s) or one (1) year experience with these manuals required.
Must have three (3) years FACETS claims processing experience including a minimum of two (2) years within the past 4 years as a Claims Adjudicator, SIU Claims Liaison, or Claims Division DTS, Unit Lead, or Quality Reviewer.
Medicare product experience preferred.
High degree of proven complex evaluative, analytical, and problem-solving skills required.
Excellent verbal and written communication skills required.
Ability to interpret and follow governments regulations required.
Knowledge of Facets pend and claims resolutions and procedures required.
Knowledge of Facets operational systems set-up, and sub-system interaction preferred.
Ability to work effectively in a team environment required.
High degree of customer service skills in order to successfully interact in a service-oriented fashion with other departments, providers and members, as an advocate for the Claims Department.
Ability to create new and modify existing documents in Microsoft Word or Excel and familiarity with Microsoft Assess required.
Knowledge of health care policies, procedures, certificates, riders and benefits as related to inquiry processing required.
Knowledge of BCN processes (i.e., capitation, referral process and financial relationships required)
Knowledge of BCN systems and operations required.
Conversant in health insurance industry terminology and working knowledge of claims payment process inter-dependence with other departments required.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Equal Opportunity Employer–minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
Please see job description for required skills.