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Sr Claims Outsourcing Analyst

Company: Blue Cross & Blue Shield of Rhode Island
Location: Providence
Posted on: August 16, 2019

Job Description:

Tuesday, July 30, 2019


Coordinate the operational aspects of claims processing services as related to the accurate and timely processing of all claims and related inquiries and adjustment requests. Act as project implementation lead for all claims related projects. Manage third party vendors and contracts for claims-related activities. Develop, maintain and perform processes to monitor the outsourcing service delivery as it relates to claims. Communicate and coordinate between user areas and the outsourcing party to minimize disruptions to claims processing and increase productivity across all areas. Participate in company-wide claims initiatives and work with users to help define claims needs to deliver the best solution.


  • Monitor and oversee the operational areas for outsourced and retained functions including desk-side services claims processing for Medicare Advantage, Commercial, FEP, EDI, OCL, ITS plans.
  • Assist with the review of all changes being made to claims processing, helping to minimize impact to the end-user. Assess the impact of major system issues and monitor the progress of resolution ensuring that all claims involved in the issue are corrected and appropriate communications are made to all critical parties.
  • Assist with the monitoring of outsourced services as related to contract deliverables.
  • Serve as liaison between internal or external business customers. Serve as an escalation point for users and trading partners when expectations are not met; identify breakdown in workflows, expedite delivery of services, implement a long-term remediation plan, and work with the user community to help streamline processes and add operational efficiencies.
  • Assist with ongoing reviews/self monitoring of claims processing as it relates to products and associated benefits sold to fully and self insured groups and individual contracts.
  • Assist with monthly monitoring of department budget for vendor fees related to outsourced services.
  • Attend necessary conferences/meetings involving claims processing changes and updates organized by CMS, BCBSA, FEP and business partners.
  • Provide subject matter expertise on claims operations-related projects to ensure the quality of the deliverables while minimizing end-user impact and costs.
  • Ensure all claims processing workflows implemented meet all internal and external regulations (e.g. HIPAA, BCBSA, CMS, etc.). Assist in creating responses to any internal or external audits and, if necessary, work with the appropriate parties to resolve any negative audit findings.
  • Mentor less experienced staff.
  • Lead department projects and initiatives.
  • Perform other duties as assigned.


    Minimum Education and Experience:

    • Bachelor's Degree in Business Administration, Management, or a related field, or equivalent experience
    • Five to seven years in claims operations
    • Three to five years experience managing claims projects
    • Experience with Disaster Recovery/Business Continuity planning

      Preferred Education, Additional Qualifications and Experience:

      • Experience in Federal Employee, Interplan Claims Process (ITS) and Other Carrier Liability (OCL)
      • Understanding of outsourcing and vendor oversight responsibilities and service level agreements

        Required Knowledge, Skills, and/or Abilities:

        • Understanding of claims operations
        • Experience in FEP, ITS, EDI and OCL (other carrier liability)
        • Understanding of claims vendor contracts, including, but not limited to, service level agreements
        • Ability to remain calm and professional in stressful situations with customers and vendors
        • Advanced analytical skills, with the ability to interpret and synthesize claims configuration and benefit processing
        • Good business acumen and political savvy
        • Knowledge of business process improvement techniques and strategies
        • Excellent verbal and written communications skills
        • Negotiation skills
        • Presentation skills
        • Decision-making skills
        • Good problem solving skills
        • Ability to interface with employees at all levels
        • Ability to effectively navigate ambiguous situations with limited direction
        • Excellent organizational skills and ability to successfully prioritize multiple tasks
        • Ability to handle multiple priorities/projects

          At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.

          The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit to view the "EEO is the Law" poster.

          Other details

          • Pay Type


Keywords: Blue Cross & Blue Shield of Rhode Island, Providence , Sr Claims Outsourcing Analyst, Professions , Providence, Rhode Island

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