Claims Systems Specialist

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You Belong At Blue

Why Join Us?

• Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
• Family Comes First: Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire
• Professional Growth Opportunities: Advance your career with ongoing training and development programs.
• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.
• Trust and Stability: Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.
• Inclusive Work Environment: We pride ourselves on fostering a workplace where everyone is valued and respected.

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package
  • Incentive pay program (EPIP)
  • Health/Vision/Dental insurance
  • 6 weeks paid parental leave for new mothers and fathers
  • Fertility/Adoption assistance
  • 2 weeks paid caregiver leave
  • 401(k) plan matching up to 5%
  • Tuition reimbursement
  • Health & fitness benefits, discounts and resources

Job Summary

Claims System Specialist will research problems in the Adjudication and Claim Entry System (ACES) as reported by ACES users and document problems in SBM.  Develop, document, test, and approve system modifications, in tandem with Information Technology & Services (IT&S) staff, in ACES needed to resolve problems or develop new functionality.  Maintain system security within ACES.  Act as a liaison between IT&S and ACES users.

This position is eligible to work remotely, hybrid, or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.
 

What you’ll do

Responsibilities: 

System Management and Support:

• Maintain, update, and troubleshoot healthcare systems related to the claims programs and peripheral systems such as membership, BGT, Provider, etc.
• Ensure data integrity and accuracy in claims processing and eligibility systems.
• Coordinate with IT and operational teams to resolve system issues and ensure seamless functionality.

Project Management:

• Participate in system upgrade projects, implementing new functionalities and enhancements to support BCBSKS operations.
• Work with cross-functional teams, including developers, analysts, and business leaders, to ensure project deliverables are met.
• Assist in the development of project plans, timelines, and documentation for system improvements.

Claims and Eligibility System Support:

• Collaborate with claims and eligibility teams to identify system needs and ensure efficient processing of claims.
• Conduct testing and validation of system changes to ensure they align with guidelines and standards.
• Develop and update workflows to enhance system capabilities for claims processing.
• Develop and document needed business requirements to modify the existing ACES system, either to correct a problem or implement new functionality, and effectively communicate those requirements to IT&S staff to guide them in developing system changes to successfully achieve said needs.  Business solutions offered must allow for a high degree of automation without jeopardizing the accuracy of claims adjudication results, quality measurements, or administrative expenses.

Data Analysis and Reporting:

• Analyze healthcare data from the system to identify trends, issues, and opportunities for improvement.
• Generate regular and ad-hoc reports to support decision-making by management.
• Monitor system performance and produce detailed analysis for system audits or compliance checks.
• Write and execute queries in QMF (mainframe) or QMF for Workstation or other SQL-based tools or applications to identify problems and/or test claim situations.

Customer Support and Training:

• Provide technical assistance to internal teams and users on system functionalities.
• Train staff on the use of new or updated system features related to the programs.
• Assist in creating user manuals, guidelines, and training materials for healthcare system applications.
• Maintain ACES user specific security settings as the ACES system administrator.

Compliance and Regulations:

• Ensure systems comply with federal healthcare regulations and data privacy laws (e.g., HIPAA).
• Stay up to date with FEP/ITS and local guidelines and health plan requirements, ensuring system modifications adhere to these standards.
• Perform and coordinate BCBSA partner plan testing requirements with other Blue Cross and Blue Shield plans for ITS system changes as assigned by management.
• As assigned by management, serve as primary point of contact for Blue Cross and Blue Shield partner plans including: Contacting other plans regarding claims problems to coordinate resolution of problems between plans. Supporting partner plan testing as a Host or Home plan. Evaluating communications from other plans and providers to determine the impact on the Kansas plan and initiate any activity required.
• Determine how to implement and integrate new ITS products pertaining to ACES.

Collaboration and Communication:

• Serve as a liaison between IT and operations teams, ensuring smooth communication and system functionality across departments.
• Communicate system issues and updates to key stakeholders in a timely manner.
• Serve as an ACES system expert to all employees of the company and research and resolve all questions submitted by fellow employees.
• Represent the Claims area in company meetings with all levels of employees, in a professional manner, as a subject matter expert.

Knowledge/Skills/Abilities

• Experience or knowledge in data processing techniques is preferred but not required.
• Must be organized, detail oriented and be able to prioritize and work on multiple different topics within any one given day.
• Existing ability to use QMF is preferred, but not required.
• Existing ability to use Rally for user story documentation is preferred.
• Existing ability to use QA Complete for test case documentation is preferred.
• Existing knowledge of MTM, FEP PIP, LDLA, BlueCard Scorecard and State of Kansas Performance Guarantees for claims transactions is preferred.
• Existing knowledge of peripheral systems such as Membership, Provider, BGT, Prime, FEP, ITS, ICD Enterprise Database, etc., is preferred but not required.
• Existing knowledge of the accumulator integration processes with Prime and Caremark is preferred, but not required

What you need

Education and Experience: 

• High school graduate or equivalent required.
• Bachelor's degree with emphasis in Computer Science, Business Administration, or Accounting is preferred.
• Must have 1 year experience in Blue Cross and Blue Shield of Kansas claims processing with a thorough knowledge of the existing ACES system.  Experience using the principles of system testing, how to thoroughly test a system when changes occur to include setting up test cases, ensuring extreme values are tested in all cases and verifying the results of both valid and invalid input, is preferred.
• Training to adjudicate claims on multiple lines of business is preferred.

Physical Requirements

• Office setting, with possible remote or hybrid work opportunities depending on the department.
• Some meetings, trainings, demonstrations, etc. require in person attendance.
• May involve long periods of time working on a computer.

Compensation

$27.08- $33.80
Non- Exempt grade 13

• Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid.  All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.

Our Commitment to Connection and Belonging

At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.

Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.