Claims Investigative Examiner
Bcidaho

Job Info

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Blue Cross of Idaho is seeking a Claim Investigator Examiner who will conduct claim reviews and investigations of health insurance fraud, waste, and abuse and processes the claims to reflect the outcome of the review and investigations. Activities and programs may include but are not limited to claim auditing, overpayment recovery activities, data mining, subrogation, third party liability (TPL), and coordination of benefits (COB).

We are looking for an Examiner with:

5 years processing complex claims and adjustments

Preferred Certification:

• Certified Professional Coder (CPC)

What a day may look like:

• Participate in the development of payment accuracy audit methods, business rules, policies, and procedures.
• Perform audits of billing, clinical, and other records.
• Interpret, apply, and compare records with company contracts, policies, legal, and regulatory requirements.
• Review and investigate claims identified by anomaly data models, fraud detection software, and other data sources, to identify incorrect reimbursement or substantiate patters of suspected activity.
• Review claim and determines denial, acceptance, or a need for further investigation.
• Review existing claims for errors and omissions.
• Process complex claims, coordination of benefits, and claims adjustments.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads.
• Ability to work independently and as a team member.
• May perform coaching and mentor employees, as necessary.
• Researcher projects, as assigned.
• Perform other duties and responsibilities as assigned.

We are also looking for:

• Facility coding experience
• Ability to read medical records and coding
• Strong creative and analytical thinking
• Strong problem solving
• Excellent verbal and written communication
• Excellent interpersonal skills
• Ability to research and navigate the system

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

This job has expired.