Adjudication, Adjudication Systems, Analysis Skills, Claims Processing, Contract Analysis, Detail Oriented, Establish Priorities, Fee Schedule, Healthcare, High School Diploma, Microsoft Excel, Microsoft Office, Microsoft Word, Network Configuration Management, Operational Support, Pricing, Problem Solving Skills, Process Improvement, Provider Contracting, Quality Management, Reimbursement, Trend Analysis
Position Summary
The Claims Repricer is responsible for the accurate review, adjustment, and application of pricing methodologies to medical claims. This role ensures claims are priced in accordance with provider contracts, fee schedules, and benefit structures. The position plays a critical role in maintaining pricing integrity, minimizing rework, and supporting operational efficiency in a high-volume claims environment.
Key Responsibilities
- Review and reprice medical claims to ensure accurate application of provider contracts, fee schedules, and reimbursement methodologies
- Analyze pricing discrepancies and perform adjustments to align with contractual and system guidelines
- Research complex claims scenarios, including escalations from Provider Services and Claims Processing
- Partner with Configuration, Network Management, and Claims teams to resolve pricing issues and system defects
- Validate contract terms and ensure proper interpretation within claims adjudication systems
- Maintain productivity, quality, and turnaround time standards in a high-volume environment
- Document findings and maintain audit-ready records of adjustments and issue resolution
- Identify pricing trends, root causes, and recommend process improvements to reduce errors and rework
Required Qualifications
- High school diploma or equivalent required; Associate's or Bachelor's degree preferred
- 2-4 years of experience in healthcare claims processing, pricing, or repricing
- Strong knowledge of claims adjudication and reimbursement methodologies (e.g., fee schedules, contract pricing)
- Experience interpreting provider contracts and pricing logic preferred
- Strong analytical and problem-solving skills with attention to detail
- Ability to manage fluctuating workloads and prioritize effectively
- Proficiency in Microsoft Office (Excel, Word) and claims systems
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
B
Blue Cross and Blue Shield Association
At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.
2,000 to 2,499 employees
https://www.bcbs.com/about-us/careers