Provider Disputes Quality Reviewer

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, identifying 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 unit’s 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 the Manager, Provider Disputes. Necessary contacts include various internal and external entities, including all levels of BCBSLA personnel, attorneys, hospitals, and physician offices.

Qualifications

Education

• High School Diploma or equivalent is required.

• Bachelor’s degree in business, finance, accounting, healthcare administration, or related field preferred

• Epic certification for Provider Disputes module as well as training certificate required within 1 year of employment

• Work Experience

• 4 years of health insurance experience is required; prefer 2 years 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

• Demonstrated experience with timely and accurate data maintenance and quality-driven methods

• Attention to detail and strong record-keeping skills

• Ability to read and interpret benefits for all lines of business

• Ability to write clear and concise reports, proposals, and business correspondence

• Strong oral and written communication, human relations, presentation, and public speaking skills

• Thorough knowledge of the claims process and adjustment procedures

• Working knowledge of PC software and applicable systems (MS Word, Excel, Outlook, etc.) and related software, including Facets and Epic; experience with Facets and Epic is required

• Strong analytical ability, including logical, systemic, and investigative thinking

• Ability to read and interpret reimbursement policies and benefits for all lines of business

• Ability to work in a rapidly paced and ever-changing environment

• Ability to work independently and demonstrate analytical and decision-making skills

• Accountabilities and Essential Functions

• Conduct random reviews on claims disputes to promote consistency, determine corporate compliance with quality and timeliness standards set by the Blue Cross and Blue Shield Association, URAC, and Provider Contractual Agreements

• Maintain a log of all case reviews, reporting errors, trends, and best practices to management

• Instruct, coach, and provide technical support to new and existing team members in Provider Disputes

• Define, execute, and administer assigned audits to ensure objectives are met, that facts are properly presented, and adequate conclusions are reached while demonstrating sound judgment

• Meet targeted deadlines required by BCBSA, BCBSLA, and department management

• Understand 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

• Resolve errors contested by specialist or leadership and adapt to changing guidelines and requirements diplomatically

• Handle other special projects/testing as assigned, such as Provider Disputes email box and intake work queues in Epic, as needed to help the department reach goals and maintain compliance

• Maintain knowledge and notes of current company policies and procedures, so SOPs can remain updated by management; assist management in updating SOPs when requested

• Additional, Physical Demands and Work Environment

• The physical demands described here are representative of those that must be met by an employee to perform the essential functions. Reasonable accommodations may be made to enable an individual with a disability to perform the essential functions

• Perform other job-related duties as assigned within scope

• 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 is required

• An Equal Opportunity Employer

• Please monitor your email frequently for communications during the recruiting process. Due to the high volume of applications, only those most qualified will be contacted. For assistance with a disability during the application process, please contact the recruiter.

• 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, 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 the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles, and credit bureaus. 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.