BCNA Claims Liaison

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Grand Rapids, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: position summary,claims,performance,investigate,procedure,analysis,research,knowledge,education,experience,insurance,teamwork,skills

Full-Time

Competitive Total Compensation Package

Overview: <p>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.</p>
Responsibilities: <ul> <li>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 BCN&rsquo;s key stakeholders. This requires following procedures which are difficult and may require manual pricing and use of external pricing programs.</li> <li>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.</li> <li>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.</li> <li>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.</li> <li>Perform other reasonably related duties, including special projects as assigned by immediate supervisor and other management staff as required.</li> </ul>
Requirements: <ul> <li> <div>High school diploma or GED required.</div> </li> <li> <div>Associates Degree or additional college credits preferred.</div> </li> <li> <div>ICD-10 and CPT-4 continuing education course(s) or one (1) year experience with these manuals required.</div> </li> <li> <div>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,&nbsp; Unit Lead, or Quality Reviewer.&nbsp;</div> </li> <li> <div>Medicare product experience preferred.</div> </li> <li> <div>High degree of proven complex evaluative, analytical, and problem-solving skills required.</div> </li> <li> <div>Excellent verbal and written communication skills required.</div> </li> <li> <div>Ability to interpret and follow government&rsquo;s regulations required.</div> </li> <li> <div>Knowledge of Facets pend and claims resolutions and procedures required.</div> </li> <li> <div>Knowledge of Facets operational systems set-up, and sub-system interaction preferred.</div> </li> <li> <div>Ability to work effectively in a team environment required.</div> </li> <li> <div>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.</div> </li> <li> <div>Ability to create new and modify existing documents in Microsoft Word or Excel and familiarity with Microsoft Assess required.&nbsp;</div> </li> <li> <div>Knowledge of health care policies, procedures, certificates, riders and benefits as related to inquiry processing required.</div> </li> <li> <div>Knowledge of BCN processes (i.e., capitation, referral process and financial relationships required)</div> </li> <li> <div>Knowledge of BCN systems and operations required.</div> </li> <li> <div>Conversant in health insurance industry terminology and working knowledge of claims payment process inter-dependence with other departments required.</div> </li> </ul> <div id="gtx-trans" style="position: absolute; left: -86px; top: 26px;">&nbsp;</div>