Provider Disputes Quality Reviewer

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.

Residency in or relocation to Louisiana is preferred for all positions.

Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.

POSITION PURPOSE

This position is responsible for reviewing transactions processed by Provider Disputes department identify trends, and systemic irregularities to improve quality performance. Document reviews then reports results to management and processor. Ensures the accurate and timely classification and processing of all levels of provider disputes received for lines of business. Ensures the units compliance with accreditation guidelines and the provider’s contractual agreement pertaining to provider claims disputes.

NATURE AND SCOPE

- This role does not manage people
- This role reports to this job: MANAGER, PROVIDER DISPUTES
- Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Various internal and external entities including, but not limited to, all levels of BCBSLA personnel, attorneys, hospitals and physician offices.

QUALIFICATIONS

Education

- High School Diploma or equivalent is required.
- Bachelor's degree business, finance, accounting, healthcare administration or related field preferred
- Epic certification for Provider Disputes module as well as training certificate required within 1 years of employment

Work Experience

- 4 years of health insurance experience is required; prefer 2 years of experience in a customer service, claims processing/adjustments (inpatient, outpatient, professional etc.) or provider relations environment.
- 3 years of experience reviewing claims for payment/processing accuracy on a quality management, administrative or medical appeal level is preferred.
- Experience in manually pricing claims and reimbursement is preferred.
- Skills and Abilities
- Must have demonstrated work experience that shows timely and accurate data maintenance and excellent quality- driven methods to produce.
- Requires attention to detail, and strong record-keeping skills.
- Must be able to read and interpret benefits for all lines of business.
- Ability to write clear and concise reports, proposals and business correspondence is required.
- Strong oral and written communication skills, human relations, presentation and public speaking skills are necessary.
- Thorough knowledge of the claims process and adjustment procedures is required.
- Working knowledge of relevant PC software and applicable systems is necessary (MS Word, Excel, Outlook, etc.) and related software as other corporate programs and applications, including but not limited to Facets, and Epic. Facets and Epic experience is required.
- Strong analytical ability is required and must include strong logical, systemic, and investigative thinking.
- Must be able to read and interpret reimbursement policies and benefits for all lines of business.
- Must demonstrate ability to work in a rapidly paced and ever-changing environment.
- Ability to work independently and demonstrate analytical and decision-making skills is required.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

- Conducts random reviews on claims disputes, in order to promote consistency, determine corporate compliance with quality and timeliness standards set forth by the Blue Cross and Blue Shield Association, URAC and Provider Contractual Agreements.
- Maintaining a log of all case reviews, reporting errors, trends and best practices to management.
- all new team members for Provider Disputes, instructs, coaches and/or provides technical support to existing team.
- Defines, executes, and administers assigned audits to ensure established objectives are met, facts are properly presented, and adequate conclusions are reached while demonstrating sound judgment/decision making and commitment to tasks.
- Meet targeted deadlines required by BCBSA, BCBSLA and department management.
- Understands applicable operational processes, policies, procedures, and tools used for processing key business transactions related to claims disputes, customer service, claims processing, administrative and medical appeals for all applicable lines of business.
- Resolves errors contested by specialist or leadership and recognizes and/or adapts changing guidelines and requirements diplomatically.
- Handles other Special projects/testing as assigned, such as Provider Disputes email box and Provider Disputes intake work queues in Epic, as needed to help the department reach goals and maintain compliance.
- Maintains knowledge/notes of current company policies and procedures, so that SOP’s can remain updated by Management. Assist management in updating SOPs when requested.

ADDITIONAL ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.

- Perform other job-related duties as assigned, within your scope of responsibilities.
- Job duties are performed in a normal and clean office environment with normal noise levels.
- Work is predominately done while standing or sitting.
- The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

All internal employees please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [email protected] for assistance.

In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.