Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We’re committed to reinventing health care to improve health for our members and the community. We hope you’ll join us.

How Is This Role Important to Our Work?

This position is responsible for the timely and accurate adjudication or adjustment of complex or difficult claims initiated by internal and external customers, providing on-the-job training and mentoring to Examiners. This responsibilities may include adjusting claims for COB, Auto, Workers’ Comp and Subrogation. It may also include researching, reviewing, and resolving money sent to BCBSMN from providers, subscribers, other Blue Plans, and/or other sources.

This role will be located within the payment integrity department and work collaboratively with team members and department/ enterprise associates who support efforts to identify aberrant provider billing.

A Day in the Life:

• Administers client specific contract benefits.
• Translate narrative descriptions into proper code.
• Research and resolve complex system edits.
• Ensure timely and accurate payment or denial of adjustments by monitoring reporting and following through with leadership or Claim Processors.
• Document any additional information or specific action taken using the proper system.
• Identify contract specific situations and manually calculate contract benefits using pricing and out-of-pocket procedures.
• Research and process or adjust high dollar claims.
• Analyze complex requests to determine how the original claim processed.
• Determine outcome of a reprocessed claim before the claim finalized. Identify and recommend areas for process improvement.
• Complete assigned special projects that require research, analysis and documentation.
• Serve on committees and task teams related to claims or adjustment efficiencies and methodologies.
• Provide on-the-job training and mentoring to Claim Processors and Associate Claim Processors.
• Research and respond to complex written correspondence via phone or in writing.

Nice to Have:

• Ability to take direction and to navigate through multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems such as Excel in order to manage workload.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within pre-defined methods and guidelines.
• Knowledge of operating systems specific to claim processing.
• Oscar claim adjustment experience.

Required Skills and Experiences:

• 3+ years of related experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• Completion of supplemental pricing or adjustment training.
• Demonstrated flexibility to adapt to changes in procedures and job assignments.
• Ability to work independently and seek solutions to problems.
• Prioritization skills in order to schedule work to meet deadlines.
• Reading comprehension skills.
• Well-developed analytical skills to evaluate and determine the appropriate course of action.
• Demonstrated ability to mentor and assist others.

Note: This role is under Stella Diversified. Stella Diversified associates are not eligible for student loan forgiveness benefit.

Make A Difference

Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.

Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.

All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.