Claims Systems Specialist

Job Summary

Claims System Specialist will research problems in the Adjudication and Claim Entry System (ACES) as reported by ACES users and document problems in SBM. Develop, document, test, and approve system modifications, in tandem with Information Technology & Services (IT&S) staff in ACES as needed to resolve problems or develop new functionality. Maintain system security within ACES and act as a liaison between IT&S and ACES users.

This position is eligible to work remotely, hybrid, or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

• System Management and Support: Maintain, update, and troubleshoot healthcare systems related to the claims programs and peripheral systems such as membership, BGT, Provider, etc.
• Data Integrity and Accuracy: Ensure data integrity and accuracy in claims processing and eligibility systems.
• Issue Coordination: Coordinate with IT and operational teams to resolve system issues and ensure seamless functionality.
• Project Management: Participate in system upgrade projects, implementing new functionalities and enhancements to support BCBSKS operations.
• Cross-functional Collaboration: Work with developers, analysts, and business leaders to ensure project deliverables are met.
• Project Planning: Assist in developing project plans, timelines, and documentation for system improvements.
• Claims and Eligibility Support: Collaborate with claims and eligibility teams to identify system needs and ensure efficient processing of claims.
• Testing and Validation: Conduct testing and validation of system changes to ensure alignment with guidelines and standards.
• Workflow Development: Develop and update workflows to enhance system capabilities for claims processing.
• Business Requirements: Develop and document needed business requirements to modify existing ACES system, communicate them to IT&S staff to guide system changes while maintaining automation and accuracy.
• Data Analysis & Reporting: Analyze healthcare data to identify trends, issues, and opportunities; generate regular and ad-hoc reports; monitor system performance for audits or compliance checks.
• Query Writing: Write and execute queries in QMF (mainframe) or QMF for Workstation or other SQL-based tools to identify problems or test claim situations.
• Customer Support & Training: Provide technical assistance to internal teams and users; train staff on updated system features; assist in creating user manuals, guidelines, and training materials.
• System Security: Maintain ACES user-specific security settings as system administrator.
• Compliance & Regulations: Ensure systems comply with federal healthcare regulations and data privacy laws such as HIPAA.

Base compensation is only one component of your competitive Total Rewards package.

• Incentive pay program (EPIP)
• Health, Vision, and Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility and Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

Apply today to be part of a trusted company with over 80 years of commitment, compassion, and community.