Claims Examiner

Claims Processing Specialist

Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including medical, dental & vision coverage, a retirement plan, generous time off including paid time off, holidays, and volunteer time off, an incentive plan, tuition reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the best places to work in PA.

This position is responsible for the coding and total processing of claims and triaging claim adjustments generated by our providers and subscribers or requested via customer service, for all lines of business. Processes claims utilizing established policies and procedures to review and correct error and warning messages. Research claims and ensures proper adjudication.

Responsibilities and Qualifications

• Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors.
• Reviews and corrects on-line edit errors by interpreting generated warning messages.
• Uses appropriate systems to research and accurately process claims. Researches appropriate reference documents and imaged claims to make coding and payment decisions.
• Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions.
• May identify and report possible system or image problems to CPR or supervisor so that corrective action may be taken.
• All other duties and assignments as directed.

Skills :

Knowledge :

Experience :

Education and Certifications :

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.