OPL Specialist II - Capital Blue Cross

Position Description:

This position is responsible for utilizing multiple automated systems/files and working with customers, group administrators, professional and facility providers, attorneys, Subrogation vendor, Plan and Par Plan personnel, and other insurance carriers and outside entities to ensure the satisfactory resolution of OPL inquiries and claims in an efficient, professional and accurate manner. Responsible for meeting BCBSA MTM standards for customer service inquiry accuracy and timeliness; and claims processing accuracy and timeliness. May also be responsible for training and auditing the work of new Specialists.

Responsibilities and Qualifications:

Receives incoming inquiries via telephone, correspondence, fax, and e-mail from individual customers, group administrators, providers, CBC personnel, par plan personnel, attorneys, insurance companies and outside entities working on behalf of the customer.

• Researches and analyzes the customer's inquiry. Determines appropriate action by reviewing and interpreting applicable policies/procedures. Utilizes manuals (on line), PC's (Image system, Money Recovery System, Right Fax, Facets, RIS, Check Tracer, Internet and Intranet) to obtain information.
• Ensures the satisfactory resolution of routine to moderately complex inquiries (e.g., claims processing, money recovery, COB, secondary payment calculation, adjustments, refunds) for line of business administered and supported by Capital Blue Cross and Capital Advantage Insurance Company.
• Responds to customers, verbally or in writing, with accurate and timely information.
• Enters all information necessary to update the Facets Customer Service files for tracking inquiry action and status. Monitors inquiries for accurate and timely resolution to ensure customer satisfaction and compliance with MTM quality and timeliness guidelines.
• Contacts the appropriate internal/external entities (e.g., groups, professional and facility providers, members, commercial carriers) to obtain information and initiate necessary action.
• Reports inquiry trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, specialized files, policies and procedures.
• May provide training to trainee specialists and audit trainee's progress and accuracy. Provides regular updates to management.
• Receives potential OPL claims from various claims production areas. Determines if COB is applicable. Accesses on-line files to determine claim and account status regarding Non-duplication, Coordination of Benefits, or ASO. Researches and/or updates computer files (e.g., Money Recovery System, Facets, , Socrates).
• Interprets other carrier benefit statements/payments or inquiries and determines the proper order of benefit payments. Codes corrections on the system. Calculates liability for claim payment and records savings to meet account savings benchmarks.
• Sets up appropriate secondary claims and determines proper payment methods when members have dual coverage and/or two Blue Cross contracts and processes accordingly.
• Determines and codes primacy for all contracts and groups. Reviews account administration enrollment applications indicating other carrier information. Updates files and initiates recovery.
• Monitors claim status for accurate and timely completion to ensure compliance with MTM quality and timeliness guidelines.

Skills:

• Familiar with PC and systems/files/software as utilized in OPL inquiry and claims processing. These include: Microsoft Office Suite, Image system, RightFax, MRS, FEP Special Information File, BlueCard/ITS, Facets, Internet and Intranet.
• Demonstrated ability to communicate effectively and professionally, both verbally and in writing, with all levels of internal and external personnel.
• Demonstrated ability to work independently and adapt appropriately to changing priorities and assignments.

Knowledge:

• Knowledge of the benefits provided by all Capital Blue Cross products. This includes the related benefit administration policies and general procedures.
• Knowledge of National Association of Insurance Commissioners (NAIC) guidelines for determining primacy.
• Knowledge of legislation impacting primacy determinations (e.g., OBRA, COBRA, TEFRA, DEFRA, HIPAA, MVFRL, Workers' Compensation Regulations).
• Knowledge of filing procedures for health care claims with other insurance carriers. Knowledge of provider billing procedures for other party payment.
• Knowledge of the Facet Customer Service files and coding structure.
• Knowledge of Claims coding structure.
• Familiar with Work Management and its impact on MTM and unit goals.
• Demonstrated proficiency in basic mathematical calculations.

Experience:

• 2 years experience as a claims examiner or customer service representative, or a combination of the two.
• Preferred experience with Subrogation or Other Party Liability in the health insurance arena.

Education and Certifications:

• High School diploma or equivalent.

Physical Demands:

Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

About Us:We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.     And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.