Claims Systems Specialist

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package
• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

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 needed to resolve problems or develop new functionality. Maintain system security within ACES. 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.; ensure data integrity and accuracy in claims processing and eligibility systems; 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; work with cross-functional teams, including developers, analysts, and business leaders, to ensure project deliverables are met; assist in the development of project plans, timelines, and documentation for system improvements.
• Claims and Eligibility System Support: Collaborate with claims and eligibility teams to identify system needs and ensure efficient processing of claims; conduct testing and validation of system changes to ensure they align with guidelines and standards; develop and update workflows to enhance system capabilities for claims processing.
• Business Requirements Development: Develop and document needed business requirements to modify the existing ACES system, either to correct a problem or implement new functionality, and effectively communicate those requirements to IT&S staff to guide them in developing system changes to successfully achieve said needs. Business solutions offered must allow for a high degree of automation without jeopardizing the accuracy of claims adjudication results, quality measurements, or administrative expenses.
• Data Analysis and Reporting: Analyze healthcare data from the system to identify trends, issues, and opportunities for improvement; generate regular and ad-hoc reports to support decision-making by management; monitor system performance and produce detailed analysis for system audits or compliance checks.
• Query Development: Write and execute queries in QMF (mainframe) or QMF for Workstation or other SQL-based tools or applications to identify problems and/or test claim situations.
• Customer Support and Training: Provide technical assistance to internal teams and users on system functionalities; train staff on the use of new or updated system features related to the programs; assist in creating user manuals, guidelines, and training materials for healthcare system applications; maintain ACES user-specific security settings as the ACES system administrator.
• Compliance and Regulations: Ensure systems comply with federal healthcare regulations and data privacy laws (e.g., HIPAA). Stay up to date with FEP/ITS and lo.