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Position Description

Arkansas Blue Cross and Blue Shield - NON-EXEMPT POSITION DESCRIPTION

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Position:  Claims Review Spec-7
Reports To: 
Division:  BA Nat'l Accts Operations (2110)
Company:  ABCBS
Location:  Label
Job Code:  53005D
Min Salary:   27400
Date Posted:  10/12/2012

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Position Specific Requirements: NA


Job Summary
The Claims Review Specialist is responsible for the accurate and timely adjudication and entry of medical claims data into the AMISYS Batch system for the Claims Division.  This may include additional investigation or communication in order to obtain necessary information to complete the claim.  The Specialist will be subject to divisional standards of quality and productivity.

The Claims Review Specialist is also responsible for the accurate correction of claims errors listed on the following reports: USD5, Batch and AHIN.  Knowledge of provider affiliations, AHIN, Filenet and general claims knowledge (i.e., CPT codes, ICD-9 codes, HCPCS codes, and claim forms) is needed to be proficient in working these error reports.  The specialist enters prescription drug claims and makes decisions to adjudicate the claims.

Nature & Scope
ENVIRONMENT

The environment is one of teamwork, in which all team members work together in order to provide excellent service through the proper/timely adjudication of claims.  Outside issues affecting this division and position include peak filing seasons, system down time, inclement weather, holidays and absenteeism.  All directly affect the volume of work for each Specialist.

WORKFLOW

Medical claims submissions may be submitted through the mail, providers, and plan participants.  Claims submissions may also be received by electronic media from providers.  Error reports will be reviewed based on department guidelines in order to maintain divisional standards of claim processing timeliness.

Normal processing includes data entry of the claim, the review and knowledge of prescription drugs, resolution of system edits, claim payment and routing claims to other areas. Claims are submitted by providers through various avenues (mail, fax and electronic media).  This position deals with paper claims that have been scanned by the Dakota Imaging system but are not able to be accepted through optical character recognition.  The specialist will obtain report information from the online reporting subsystems (VISTA and AHIN) or by paper copies of claims and research information using the Filenet system.  Claims information is keyed into the AMISYS Batch system.  

As part of the entry and/or correction process, the Claims Review Specialist may have to search for member and provider information using the AMISYS, ABCBS mainframe, Provnet, Filenet and AHIN subsystems.  Development includes telephone calls to providers and internal personnel, generating correspondence, and completing forms to obtain information necessary for claim adjudication.  

GUIDANCE

Corporate and professional books guide the activities of the Claims Review Specialist including the ICD9, CPT4 and HCPS Procedure Codebooks and processing manuals located on the BlueAdvantage Intranet. System edits, flags and numerous claim procedure memos also guide the process.  Self-guided decisions are based on knowledge obtained from the initial training course, on-the-job training and continuing education (i.e., medical terminology, etc.)  The specialist receives direction from the supervisor and/or manager.

CHALLENGES

Continually changing processing procedures, resolving the error reports & processing non-standard claims in an accurate, timely manner, and systems modifications represent the most difficult challenges for this position.  The Claims Review Specialist must be knowledgeable of and have the ability to access all relevant systems.  The Claims Review Specialist is challenged to meet government, corporate and national standards (MTM) while maintaining acceptable performance levels based on established department standards for production and quality.

INTERFACES

This position may interface regularly with the following:
External-Providers in the development of claims information.
Internal-A broad cross section of internal departments.

AUTHORITY

This position has the authority to resolve error reports, develop, process and refer claims to management or other divisions.  They are authorized to return claims to providers and/or members that do not contain specific information needed for the entry of the claims into the AMISYS system.  This position also has the authority to make suggestions for improvement to the claims processing and development procedures.

Minimum Job Requirements
1. Office experience OR college courses (48 semester hrs) or other equivalent certification with emphasis in anatomy, medical terminology, math, biology, etc.
2. High school diploma (or equivalent)
3. Interpersonal skills-competent
4. Keyboard and personal computer skills
5. Basic English and reading comprehension skills
6. Basic math skills
7. Good oral communication skills
Testing needed:
Data Entry - Alpha & Alpha-numeric
Claims Assessment

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1.  Process non-standard claims (including prescription drug claims)
    A. Edit/Audit resolution
    B. Review, interpret and apply benefits for prescription drug claims
    C. Determine eligibility
    D. Identify claims processing problems related to non-standard claims

2.  Work AMISYS error reports (including AHIN, BATCH, USD5)
    A. Edit/Audit system edits
    B. Determine eligibility
    C. Research/Verification of provider information

3.  Claims Development
    A. Written memos including completing forms
    B. Emails to internal departments, etc.
    C. Research claim problems via systems and manuals

4.  Perform other duties as assigned which may include but not limited to providing back up support for other areas such as, Development and/or Submission; special assignments to other areas needing support, and special projects as directed by the supervisor and/or manager.
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