Adjudication, Analysis Skills, Claims Processing, Communication Skills, Contract Analysis, Corrective Action, Documentation, Establish Priorities, Healthcare, High School Diploma, Medical Treatment, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft Word, Network Configuration Management, Operational Strategy, Pricing, Problem Solving Skills, Process Improvement, Provider Contracting, Quality Metrics, Reimbursement, Root Cause Analysis, Time Management, Training/Teaching, Trend Analysis
LOCATION
Philadelphia, PA
POSTED
24 days ago
Job Profile Summary
The Provider Claims Service Specialist is responsible for responding to provider inquiries and resolving issues related to claims processing, reimbursement, and pricing. This role acts as a liaison between providers and internal claims operations teams to ensure accurate, timely resolution and a high level of service in a fast-paced environment.
Key Responsibilities
Research and resolve provider inquiries related to claim status, pricing, reimbursement, and contract interpretation
Analyze claim processing issues to identify root causes and implement corrective actions
Collaborate with internal departments (e.g., Claims, Configuration, Network Management) to address escalated issues
Review and interpret provider contracts to ensure accurate claims adjudication
Monitor and manage assigned work queues to meet productivity and quality standards
Maintain detailed documentation of issue resolution and provider interactions
Identify trends and recommend process improvements to enhance operational efficiency and provider experience
Support provider education by explaining claim outcomes, policies, and procedures
Required Qualifications
High school diploma or equivalent required; Associate's or Bachelor's degree preferred
2-4 years of healthcare claims processing or provider services experience
Strong knowledge of medical claims adjudication and reimbursement methodologies
Familiarity with provider contracts and pricing logic preferred
Excellent analytical, problem-solving, and communication skills
Ability to manage high-volume workloads and prioritize effectively
Proficiency in Microsoft Office (Excel, Word, Outlook) and claims processing systems
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
About the Company
B
Blue Cross and Blue Shield Association
At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.