Job Details

Medical Review Claims Analyst

The Medical Review Claims Analyst is responsible and accountable for timely and accurate non-clinical reviews of Blue Cross and Blue Shield, National & Special, State, Federal, ITS claims and CSC inquiries to support corporate timeline goals. Responsible for accurate and timely responses to internal and external inquiries involving requests for explanation of contract coverage, coding, and claims payment. Responsible for identifying aberrant provider activity and opportunities for provider education and refer for appropriate intervention. This position is eligible to work onsite, remote or hybrid (9 or more days a month on site) in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us

Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.

Family Comes First: Total rewards package that promotes the idea of family first for all employees.

Professional Growth Opportunities: Advance your career with ongoing training and development programs.

Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.

Flexibility: Options to work onsite, hybrid or remote available.

Balance: Paid vacation and sick leave with paid maternity and paternity available immediately upon hire.

Compensation $23.58 - $29.40 hourly Non-Exempt 12 - Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individuals skills, education, experience, and training. The range may vary above or below the stated amounts.

What Youll Do

Responsible for independent non-clinical review of claims and inquiries using contracts, medical policies, internal guides, and desk process.

Ensure claims and inquiries are processed timely and accurately according to contract, corporate, and federal guidelines.

Responsible for identifying when a non-clinical review should be elevated to a higher level of review, i.e., nurse consultant, management, consultants.

Responsible for researching history, identifying appropriate guidelines, and formatting clear concise question(s) for claims needing nurse, management, or outside consultant review.

Responsible for providing support to internal staff (i.e., Marketing, Hotline, CSC), regarding questions about coding, claim processing, and pricing issues.

Responsible for maintaining current knowledge regarding coding, contract language, system editing, and pricing guidelines.

Responsible for identifying areas of aberrant utilization for provider education, guideline, and system changes.

Participates in department and cross-divisional teams.

Must follow URAC standards as required for essential job functions.

What You Need

Knowledge/Skills/Abilities:

Must be able to comply with and implement corporate information security policies, standards, and guidelines relative to access control.

Must be self-directed with the ability to make independent decisions and prioritize personal and employee production activities.

Must have strong computer skills in order to operate effectively with company systems and programs.

Proficient in Excel, WORD, OneNote, and other department used systems.

Must be able to maintain a productive and professional relationship with multiple cross departmental and divisional teams.

Must be able to maintain an excellent record of attendance.

Must have a strong analytical background.

Must be able to use medical terminology/medical diagnostic and procedure information, ICD-10, CPT, HCPCS coding to accurately review and complete claims activity.

Education and Experience:

High school graduate or equivalent - required.

At least three years of BCBSKS Claims or CSC experience AND/OR American Academy of Professional Coders certification with at least 2 years of coding experience or at least 3 years of medical coding experience - required.

Thorough knowledge of multiple product lines, contracts, and related operating policies with preference to FEP, Blue Choice, State of Kansas, and Interplan Teleprocessing System (ITS) - Preferred.

Thorough knowledge of CSI, Reimbursement Schedules, Ask Oz, ACEs, Clai