Denied Claims Specialist

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Position Summary:
The Denied Claims Specialist supports the FEP Service Center team as the primary resource for the FEP Disputed Claims Process (Reconsiderations) and supports associates as part of the Member Service Leadership team. Manages and resolves incoming disputed claims in accordance with FEP guidelines, quality, and timeliness requirements.

Key Accountabilities:
Assist FEP members by investigating, analyzing and solving disputed claim requests within performance measurement timeliness and accuracy guidelines
Coordinates activities of internal BCBSMA resources related to disputed claim reviews
Assists member service associates with expertise in FEP benefits, systems and processes particularly related to disputed claims
Reports activity and performs trend analysis of disputed claims
Assist in the development and implementation of process improvements

Challenges/Problem Solving:
Assist FEP associates with issues related to the disputed claims process
Meet or exceed stringent deliverable dates established by outside entities
Multiple requirements due on or around the same timeframes
Comprehend complex benefits and claim processing guidelines
Work effectively with dual system claims processing platforms
Federal Account with unique rules and regulations

Decision Making Authority:
Primary resource for resolution disputed claims in accordance with FEP regulations and guidelines
Positively impact the FEP Performance Measurement Framework Model by making sound business decisions

Leadership Responsibilities:
Communication of issues to associates on disputed claims issues
Participate in the design and measurement of new technical and business initiatives that will enhance member satisfaction
Role model to other associates by demonstrating BCBSMA core values of honesty, integrity, responsiveness, fairness, respect, consistency and team work. REQUIREMENTS
Qualifications (knowledge/skills/abilities/behaviors):
Thorough knowledge of TPS, RTMS and FEP Express/Direct
Specific knowledge of FEP contracts, Standard Option and Basic Option
Strong verbal and written communication skills, and attention to detail are essential
Demonstrated qualitative and analytical skills
Self motivation/ organizational abilities to handle multiple priorities, and meet strict deadlines in a fast-paced environment
Strong PC skills including MS Office
Demonstrates independent thinking and resourcefulness

Education/Relevant Experience:
BS/BA degree preferred or equivalent work experience
Superior working knowledge of all benefits under the FEP contract