We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSE
This position handles compliance issues which include new laws, mandates and regulations from DOI and federal government along with the tracking, updating, maintenance and reconciliation of the groups who participate in the Retiree Drug Subsidy. This position will also handle all setup and maintenance on Medicare Secondary Payer. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.
NATURE AND SCOPE
This role does not manage people
This role reports to this job: SUPERVISOR, ENROLLMENT & BILLING
Necessary Contacts: To do this job effectively the incumbent has to be in contact with:CMS, Information Technology, Marketing, Legal, Underwriting, Pharmacy Services, Other Party Liability, Research, Claims Units, Customer Service, MTM, other Benefits Specialists and other departments within BCBSLA as needed, other plans, outside consultants, agents, brokers, group leader and subscribers as needed.
QUALIFICATIONS
Education
High School Diploma or equivalent is required
Associate's is preferred
Work Experience
5 years in insurance operations with knowledge of billing, reconciliation and/or collections, compliance, working appealed cases or problem/special cases is required
Skills and Abilities
Strong analytical, decision-making, organizational abilities, oral and written communication skills, and interpersonal skills are necessary.
Able to identify problems, complex business needs and develop solutions/resolve problems.
Must be able to work independently and prioritize multiple responsibilities in order to meet aggressive deadlines.
Must have strong collaboration and leadership skills in order to work with employees at higher levels and in meetings to resolve discrepancies
Working knowledge of relevant PC software required.
Experience in writing system narratives and specifications and in reviewing completed system tests is preferred
Experience in developing system solutions for membership/enrollment administration preferred.
Understanding of insurance laws, PHI, and Facets screens is preferred.
Licenses and Certifications
None Required
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
Conducts research to determine if member qualifies for Medicare Carveout rates and updates member records to reflect or remove Medicare Carveout rates and RDS eligibility. Resubmits any members that should be RDS Eligible if rejected by the Center for Medicare Services.
Researches CMS system and updates BCBSLA systems to ensure enrollment information is accurate and up to date. Reviews all response files received from CMS and any Error or Absent Reports received from ESI and makes any necessary corrections. Reviews and works all reports that need to be resubmitted and/ or verified with CMS for Medicare Secondary Payer (MSP).
Communicates with all areas to ensure accuracy of data between BCBSLA, EDI and CMS.
Conducts research on new compliance issues/problem cases and facilitates meetings with appropriate departments to implement new laws and policies and procedures.
Coordinates the mass mailing of MSP letters to groups once a year to collect group size and Tax ID numbers to ensure no fines are levied on the company. Updates group record to reflect information being provided by the group.
Reviews and reconciles list of potential members from IT and forwards to the group and account manager requesting validation. Reviews and reconciles list of potential members from the group leader and forwards to CMS.
Researches member records to obtain missing information to ensure records are accurate. Contacts group leaders to obtain missing information for Medicare.
Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
Perform other job-related duties as assigned, within your scope of responsibilities.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document, calculate, visualize, and analyze are required.
An Equal Opportunity Employer
All internal employees please apply through Workday Careers.
PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional Information
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
JOB CATEGORY: Insurance
