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Position Description

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

Position:  Claims Specialist - 8
Reports To: 
Division:  Blue Card/Reg Bus Clms (0003)
Company:  ABCBS
Location:  Label
Job Code:  53001E
Min Salary:   29800
Date Posted:  1/25/2013

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Position Specific Requirements: None

Job Summary
The Claims Specialist is responsible for accurate and timely adjudication of medical claims. 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.

Nature & Scope

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, systems issues, inclement weather, holidays and absenteeism. All directly affect the volume of work for each Specialist.


Claims submissions are received by electronic media from providers. They may also be submitted through the mail, providers, and plan participants.  Pending claims 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 interpretation of  plan profiles and edit/audit resolution, claim payment and routing claims to other areas. Development includes telephone calls to providers and internal personnel, generating correspondence, and completing forms to obtain information necessary for claim adjudication. Medicare primary claims require numerous development steps in order to interpret Medicare's payment, coordinate benefits and make the appropriate payment. Processing of some claims may require reviewing letters from physicians to determine benefit eligibility.  In addition to the review of pending and aged claims reports


Corporate and professional books guide the activities of the Claims Specialist and manuals including the Processing Manual located on TextBOOK, Diagnosis book and the ICD9, CPT4 and HCPS Procedure Code book. 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.


Continually changing processing procedures, benefits and systems modifications represent the most difficult challenges for this position. The Specialist must be knowledgeable of and have the ability to access all relevant mainframe systems as well as ProvWEB, AHIN, FileNET, Customer Service Workstation (CSW) and Blue2 screens in order to process claims accurately. The Specialist is challenged to process claims in an accurate and timely manner in order to meet  BlueCard Association, corporate and Licencee Desk Level Audit Standards (LDLA} while maintaining acceptable performance levels based on established department standards for production and quality.


This position may interface regularly with the following:

External: Providers and  other Blue Cross Plans- development of claims information.
Internal: A broad cross section of internal departments, including the regions.


This position has the authority to develop, process (pay) and refer claims to management or other divisions. This position also has the authority to make suggestions for improvement to the claims processing and development procedures.

Minimum Job Requirements

High School Diploma, College courses in English composition are preferred.

Alpha and Numeric Entry - minimum of 7,000 keystrokes per hour

Office experience, i.e. claims processing, health insurance, medical or office or

2 years college (48 semester hrs) or other equivalent certification with emphasis on anatomy, medical terminology, math, biology, etc.

Complete company proficiency test on math, reasoning, data entry, typing, and reading.

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.

1. Process Claims
a. Data entry claims
b. Edit/audit resolution
c. Review, interpret and apply benefits
d. Determine eligibility
e. Identify claims processing problems
f. Apply Association processing standards

2. Development
a. Write memos and complete forms
b. Consult internal staff and medical providers
c. Research claim problems via systems and manuals

3. Perform other duties as assigned which may include but is 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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