Claims Examiner II

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<p><span>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.</span></p><p></p><p><span>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.</span></p><p></p>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. <br><br>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.<p style="text-align:inherit"></p><p style="text-align:inherit"></p><p><b>What you'll do:</b></p><p>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:</p><ul><li>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.</li><li>Efficiently use multiple systems and screens to obtain and record claim information.</li><li>Follow all relevant policies and procedures.</li><li>Review medical record documentation, authorization information and member benefit coverage to determine the extent of liability for payment.</li><li>Process claims within quality and production standards.</li><li>Make determinations on the appropriate adjudication of complex claims independently.</li><li>Review claim disputes submitted by member and providers to include urgent internal department requests.</li><li>Take initiative and learn to assist other lines of business for Claims Examiner I level work.</li><li>Identify areas of concern that may compromise member, provider and group satisfaction.</li><li>Identify claims that suggest a potential issue or problem with the claim system configuration or provider contract configuration.</li><li>Communicate any issues as appropriate for research and correction.</li><li>Provide feedback to ensure identification of quality trends and opportunities.</li><li>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.</li><li>Participate in special projects, as needed.</li><li>Provide ideas and suggestions to ensure member and provider satisfaction.</li><li>Partner with less experienced associates to improve the overall knowledge and performance of the team and the division as a whole.</li><li>Promote teamwork.</li><li>All other duties as assigned by Claims Leadership.</li></ul><p style="text-align:inherit"></p><p style="text-align:inherit"></p><p><b>To be considered for this position, you must have:</b></p><ul><li>High School degree.</li><li>Proficiency as a Claims Examiner I or relevant healthcare experience.</li><li>Excellent verbal and written communication skills.</li><li>Proficiency with MS Office applications.</li><li>Team collaborator.</li><li>Must be able to work with minimal supervision.</li><li>Creative thinker with good problem resolution skills related to the healthcare claim adjudication.</li><li>Strong work ethic with ability to multi-task when needed.</li></ul><p></p><p>Learn more about what makes BCBSNE such an exceptional place to work by visiting <a href="https://www.nebraskablue.com/en/About-Us/Careers" target="_blank" rel="noopener noreferrer"><span style="overflow-wrap: break-word; display: inline; text-decoration: inherit; hyphens: auto;">NebraskaBlue.com/Careers</span></a>.</p><p></p><p><i>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.</i></p><p></p>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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