OPL Investigator I

OPL Investigator I Remote within: OR, WA, ID and UT Primary Job Purpose: Responsible to maximize savings in third party situations, including accidents, medical malpractice, and occupational injury claims, while supporting members in navigating the health care system. Must thoroughly, accurately, and promptly investigate and analyze incoming claims, claims histories, systems notes, customer service tracking, returned incident reports and correspondence to identify and obtain maximum savings in third party liability situations. Must appropriately code multiple systems to maximize savings and future savings, ensure appropriate claims processing, and produce timely, thorough, and accurate follow-up, documentation, and investigation. Must identify and obtain all necessary information in potential subrogation situations, code subrogation tracking system, and triage and hand off subrogation files and correspondence and phone calls appropriately. Responsibilities: Works closely with OPL clerks, clerk-analysts and subrogation Coordinators to maintain the proper flow of Other Party Liability cases received for review and additional investigation. Reviews and investigates third party claims for maximum savings through appropriately applying contract exclusions with accurate coding of all applicable claim systems. Accurately sets up proper documentation and instruction in the claims and tracking systems. Notifies members, attorneys and other pertinent parties of investigative findings. Reviews and thoroughly investigates all Incident Reports determined to be third party. Contacts attorneys, members, adverse carriers and others as needed to gather all pertinent information regarding OPL issues Helps members navigate their health care by accurately explaining the payment order when our exclusion applies. Determines when other liability coverage’s have expired or exhausted and updates processing instructions promptly and accurately Follows up on all leads received Accurately and thoroughly handles incoming work to meet the timeliness standards Identifies and sets up possible subrogation action by working with subscribers, providers, insurance companies and attorneys, either by correspondence or telephone Reviews, investigates, and reconciles Company claim history with payments made by the third party payment logs to avoid duplicate payment. Establishes correct payment order among parties involved. Makes appropriate adjustments to either deduct claim, request refunds or process to contract benefits. Responds to telephone and written inquiries from attorneys, insurance adjusters, providers and subscribers regarding subrogation liens, claims processes, and investigates fully all aspects of possible other party coverages available. Keeps abreast of changing state laws regarding the order of payment and applicable exclusion and third party claims. Communicates Company position to all parties associated to a third-party claim. Utilizes appropriate file management, reporting and savings tracking systems; prepares weekly and monthly statistics on work record/profile. Maintain work in a current status per department guidelines. Minimum Requirements: Demonstrated professional oral and written communication skills including the ability to work effectively with other team members, vendors and stakeholders. Excellent interpersonal skills Basic knowledge of medical terminology, CPT and ICD-10 coding required Understanding of OPL rules and regulations which are governed by the contract exclusions preferred Basic knowledge of health insurance claims systems and associated documents Ability to work with a high volume of claims and correspondence while keeping detailed and accurate records Strong analytical ability Strong organizational, problem-solving, and time-management skills Ability to exercise initiative and independently make decisions within the scope of assigned authority and to assume responsibility while operating with a minimum of supervision Ability to work as part of a team and demonstrate efficiency Ability to meet established deadlines, be able to quickly and accurately triage and be flexible in evaluating competing priorities, and be responsive, available, and timely Proficient use of Microsoft Word and Excel Understanding of subrogation principles and applicable laws preferred Basic understanding of primary and secondary insurance and related legal and contractual guidelines Basic knowledge of reconciliation of PIP ledgers and associated documents and how to initiate appropriate refunds, deducts, and adjustments Normally to be proficient in the competencies listed above: OPL Investigator I would have an Associate’s degree and 2 years of job-related work experience or equivalent combination of education and experience. #LI-remote Work Environment: May be required to work overtime. May be required to work outside normal hours No unusual working conditions The base pay annual salary range for this job is $18.90-$28.00/hour, depending on candidate's geographic location and experience. The annual incentive payment target for this position is 5%. Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights: medical, dental, and vision coverage for employees and their eligible family members annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date) paid time off varying by role and tenure in addition to 10 company holidays up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period) up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption) one-time furniture and equipment allowance for employees working from home up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page. We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site. Everyone is a health care consumer deserving of a simpler, more personalized experience. Cambia is transforming the health care system to revolve around people. For over 100 years we’ve designed people-first health solutions rooted in the nation’s first health plan, a loggers’ wage pool established in the Pacific Northwest. Today that pioneering spirit aligns our family of over 20 companies, including 4 not-for-profit BlueCross and BlueShield licensed health plans serving over 3 million Americans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices. Interested in driving accessibility, affordability and quality health care for real people? Apply to any of our open jobs or join the Twitter conversation @Cambia. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

Salary : $19 - $28