Claims Processing Specialist I - Fulltime Remote in WA, OR, ID and UT
Cambia Health Solutions, Inc
Primary Job Purpose
Remote within WA, ID, OR and UT
Following federal mandate, all Cambia Health Solutions employees, including 100% remote workers, need to be fully vaccinated for COVID-19 by 1/1/22.
Claims Service Specialist I processes a variety of claim types and product lines to maintain the complete claims processing cycle for multiple functions/edits.
General Functions and Outcomes
Process claims that are not eligible for auto-processing due to benefit structure or complexity of claim type or have been referred by Claims Analysts. Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims.
Recognize all policies and procedures that apply to claims and quickly reference documentation for details.
Make informed decisions regarding the disposition of claims; may include payment or denial of claims, or requests for further information, for all lines of business within Cambia.
Work with Customer Service and Membership staff on claims issues/problems to enhance the Member Experience.
Perform at a high level meeting production requirements and quality standards, including group performance guarantees.
Adapt to changes that affect the job, including contract changes as well as procedure or system changes to ensure correct processing of claims.
Adapt to daily changes in workload/responsibilities based upon Claims Division goals/priorities.
Organize, maintain and keep readily accessible, all references, documents, policies and procedures to ensure correct application of contract benefits.
Perform work in an orderly fashion and provide clear audit trails so others can easily complete work in case of absence.
Analyze and investigate claims in order to process or reprocess claims in a timely and accurate manner.
When processing issues/problems are recognized, taking responsibility to research and work with appropriate staff/departments, persevering to achieve resolution.
Validate provider and service information. May contact insurance companies, group administrators, providers, agents/brokers, subscribers and other member representatives to obtain missing or incomplete information.
May manually verify and compute pricing amounts for claim. Utilized as a contact and resource to process or adjust claims when system issues or problems are identified.
Maintain confidentiality in all aspects of claims processing, including correspondence and contacts.
Comply with MTM and Consortium standards as they relate to the employee’s responsibility to meet BlueCross BlueShield Association (BCBSA) standards and corporate goals.
Assist all levels of claims analysts and all other internal customers with questions, training and adjudicating complex or difficult claims.
Respond quickly to new instructions and adapt to changes such as contract and/or procedure changes and system upgrades or enhancements.
May review and reprocess previously adjudicated claims.
Identifies the need for and provide feedback for system(s) improvements.
May generate effective written correspondence to multiple areas.
Demonstrates the ability to apply critical thinking skills.
Demonstrate understanding of medical terminology and ICD-9/CPT coding.
Provide excellent customer service to customers, providers, members, brokers, member representatives and all levels of internal staff.
Computer experience and familiarity with software, such as MS Word and Excel, or other comparable programs.
Ability to work independently as well as a member of a team.
Ability to work under pressure and meet deadlines. Must be highly adaptable and flexible with workload based upon the Claims Division goals/priorities.
Communicate effectively orally and in writing. Ability to communicate complex claims processing information in writing when responding to internal customers regarding issues/questions.
Excellent interpersonal skills and the ability to work with all levels of staff.
Ability to organize and prioritize workload and to meet deadlines.
Demonstrate strong analytical ability in identifying problems and strong skills in performing in-depth investigation, judgment in developing solutions and implementing a course of action.
Meet job quality, quantity, timeliness, knowledge and dependability requirements as described by department goals.
Ability to create reports for management.
Normally to be proficient in the competencies listed above
Claims Specialist I would have high school diploma or equivalent and 1 year of claims experience or equivalent combination of education and experience.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you’re seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers’ engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email