Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

As a Claims Examiner you will be responsible for the adjudication of healthcare claims utilizing employer and payer specific policies and procedures. Responsible for reviewing the data in the claims processing system and compare with corresponding CMS and billing guidelines. Responsible for reviewing medical claims attachments when necessary to determine if services rendered was medically appropriate and benefit coverage criteria has been met. Responsible for reviewing adjudication software system’s claim and line item edits for determination of whether to pay claim/line item(s). May forward claims to specialized internal and external resources. Corresponds with other departments as necessary to process claims. Accountable to performance metric scorecards.

What you'll do:

• Responsible for interpreting claim adjudication rules to process and/or adjust simple claims. Daily accountability for meeting production and quality standards by performing the following:
• Analyze claims for accuracy and completeness to determine benefits based on specific member and provider contracts, payment rules, eligibility status, COB requirements and provider status in a timely manner.
• Efficiently use multiple systems and screens to obtain and record claim information.
• Follow all relevant policies and procedures.
• Review medical record documentation, authorization information and member benefit coverage to determine the extent of liability for payment.
• Process claims within quality and production standards.
• Make determinations on the appropriate adjudication of claims with the assistance of leads or other more experienced examiners.
• Approaching and progressing towards a Claims Examiner II skillset.
• Identify areas of concern that may compromise member, provider and group satisfaction.
• Identify claims that suggest a potential issue or problem with the claim system configuration or provider contract configuration
• Communicate any issues as appropriate for research and correction.

To be considered for this position, you must have:

• High School degree required with one year of relevant professional experience.

• Excellent verbal and written communication skills.

• Proficiency with MS Office applications.

• Team collaborator.

• Must be able to work with minimal supervision.

• Creative thinker with good problem resolution skills related to the healthcare claim adjudication.

• Strong work ethic with ability to multi-task when needed.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans