1 customer service representative technical support jobs found

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: To support the prevention, reduction of and/or recuperation of losses to CareFirst through the clinical review of medical records and claims, resulting in the savings and/or recovery of funds. Responsible for providing clinical knowledge to the SI team to support both prepayment reviews and/or post-payment investigations. ESSENTIAL FUNCTIONS: Review of medical records and claims. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or post payment environment. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards. Process all assigned claims or batch case reviews...