Sr Claims Outsourcing Analyst
Company: Blue Cross & Blue Shield of Rhode Island
Posted on: August 16, 2019
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
ESSENTIAL JOB FUNCTIONS:
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
- Assist with the monitoring of outsourced services as related to
- 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
- 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
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
- 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
- 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
- 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
view the "EEO is the Law" poster.
Keywords: Blue Cross & Blue Shield of Rhode Island, Providence , Sr Claims Outsourcing Analyst, Professions , Providence, Rhode Island
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