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Claims Policy Analyst II

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BlueCross BlueShield of South Carolina

Aug 29, 2024

  • Job
    Full-time
    Senior Level
  • Columbia
  • Quick Apply

AI generated summary

  • You need a Bachelor's degree or equivalent experience, 3 years in the industry, 2 years in project admin, strong technical, analytical, and Excel/Word skills, plus knowledge of Medicare Part B.
  • You will analyze claims directives, maintain processing procedures, educate staff, resolve inquiries, manage reports, and lead projects while assisting less senior analysts.

Requirements

  • Required Education: Bachelor's degree
  • Degree Equivalence: 4 years job related work experience or Associate's and 2 years job related work experience
  • Required Work Experience: 3 years of industry specific work experience. 2 years of project administration experience.
  • Excellent technical skills including knowledge of claims system.
  • Ability to lead and direct others on assignments.
  • Skilled at project management.
  • Ability to persuade, negotiate or influence.
  • Strong organization, analytical and decision-making skills.
  • Good personal computer skills.
  • Thorough understanding of required legislation, guidelines and regulations.
  • Ability to handle confidential or sensitive information with discretion.
  • Required Software and Tools: Microsoft Office
  • Experience with Medicare Part B
  • Strong Excel and Word skills

Responsibilities

  • Reviews, analyzes, researches and interprets all directives and/or claims system update releases.
  • Identifies all changes needed and prepares and submits claims system maintenance request. Verifies and approves changes to processing procedures and claims system. May add codes to the system and verify maintenance and testing.
  • May serve as liaison between management and less senior staff on management reports, and implementation of documents and mandates.
  • Approves changes to the on-line claims processing procedure manual and communicate claim processing changes to other areas of relevant operation.
  • May develop and issue examining memos/help screens and claims processing instructions and provide education on all claims system changes.
  • Acts as a functional system and claims policy subject matter expert for the area. Researches and responds to inquiries and/or provider escalations.
  • Assists the Provider Call Center when subject matter expert is needed to resolve the caller's inquiry.
  • Assists less senior staff, management and other areas of the operation.
  • Function as lead for mandates and projects while guiding less senior analysts for departmental management. Maintains and monitors existing edits/audits and requests maintenance updates as needed.
  • Analyzes and responds to assigned Claims.
  • Compiles and reviews monthly/quarterly reports and notifies management of any outstanding issues or problems that could affect critical business processes.
  • Reviews items for management, identifies discrepancies, gathers explanatory information and makes recommendation on necessary actions or response.
  • Directs less senior analysts and create action plan to follow protocol to ensure compliance in annual updates.
  • May build new rules and/or add new codes to the claims system, delete invalid codes from the claims system, and educate the staff on changes.
  • Assist manager with assignments and special projects.

FAQs

What is the primary role of a Claims Policy Analyst II?

The primary role is to interpret directives and policies to establish processing guidelines for claims, work with the systems department to create and maintain edits/audits in the claims system, and serve as a subject matter expert.

What are the working hours for this position?

This position is full-time, working 40 hours per week, Monday to Friday.

Where is the job located?

The job is located onsite at GPC – 17 Technology Circle, Columbia, SC.

What qualifications are required for this position?

A Bachelor’s degree is required, or an equivalent of four years of job-related work experience, or an Associate's degree with two years of job-related work experience, along with three years of industry-specific experience and two years of project administration experience.

What specific skills are needed for the Claims Policy Analyst II role?

Required skills include excellent technical skills related to claims systems, project management skills, strong analytical and decision-making abilities, and the capability to handle confidential information with discretion.

Is experience with Medicare Part B preferred for this position?

Yes, experience with Medicare Part B is preferred.

What software skills are necessary for this job?

Proficiency in Microsoft Office, particularly Excel and Word, is required.

Are there opportunities for career development and advancement within the company?

Yes, the company emphasizes diversity and inclusion, providing employees with opportunities to develop skills and advance their careers.

What benefits does BlueCross BlueShield of South Carolina offer?

The comprehensive benefits package includes subsidized health plans, dental and vision coverage, a 401K retirement savings plan with company match, life insurance, paid time off (PTO), tuition assistance, wellness programs, and more.

What is the process after submitting an application for this position?

After submitting your application, the recruiting team will review your resume. This may include a brief telephone interview or email communication to verify resume specifics before management conducts interviews with qualified candidates.

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BlueCross BlueShield of South Carolina

South Carolina’s largest and oldest health insurance company

Finance
Industry
10,001+
Employees
1946
Founded Year

Mission & Purpose

BlueCross BlueShield of South Carolina, the state's largest insurance company, has been a part of the national landscape for over six decades. With an A+ Superior rating from A.M. Best, the company is a leading government contract administrator and operates one of the most advanced data processing centers in the Southeast. BlueCross offers employees robust benefits, including retirement plans, health coverage, and education assistance, while fostering a culture of community support, with employees actively contributing to numerous nonprofit organizations each year.