Claims Investigative Examiner

Blue Cross of Idaho is seeking a Claim Investigator Examiner who will conduct claim reviews and investigations of health insurance fraud, waste, and abuse and processes the claims to reflect the outcome of the review and investigations. Activities and programs may include but are not limited to claim auditing, overpayment recovery activities, data mining, subrogation, third party liability (TPL), and coordination of benefits (COB).

Experience: 5 years processing complex claims and adjustments

• Certified Professional Coder (CPC)

• Participate in the development of payment accuracy audit methods, business rules, policies, and procedures.
• Perform audits of billing, clinical, and other records.
• Interpret, apply, and compare records with company contracts, policies, legal, and regulatory requirements.
• Review and investigate claims identified by anomaly data models, fraud detection software, and other data sources, to identify incorrect reimbursement or substantiate patters of suspected activity.
• Review claim and determines denial, acceptance, or a need for further investigation.
• Review existing claims for errors and omissions.
• Process complex claims, coordination of benefits, and claims adjustments.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads.
• Ability to work independently and as a team member.
• May perform coaching and mentor employees, as necessary.
• Researcher projects, as assigned.
• Perform other duties and responsibilities as assigned.

• Facility coding experience
• Ability to read medical records and coding
• Strong creative and analytical thinking
• Strong problem solving
• Excellent verbal and written communication
• Excellent interpersonal skills
• Ability to research and navigate the system

As of the date of this posting, a good faith estimate of the current pay range is $60,048 to $84,069. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).

The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.