Jordan G.

About Jordan G.

Early career IT professional with experience supporting enterprise systems, routing…

Experience

1. Claims Specialist

   CareFirst BlueCross BlueShield

   Apr 2023 — Present · US

   Adjudicate professional and facility claims in FACETS, applying plan benefits, coordination of benefits (COB), medical policy, and prior authorization requirements in alignment with federal and state regulations.• Interpret and apply ICD-10-CM, CPT/HCPCS, and modifier rules to ensure claims are processed accurately and in compliance with NCCI edits and payer policy. • Research and resolve claims status, benefits, eligibility, and EOB/Remittance inquiries, providing members and providers with clear explanations and resolution pathways. • Process denials, adjustments, and overrides with documented rationale; collaborate with cross-functional teams including Appeals & Grievances, Payment Integrity, Provider Relations, and Enrollment to resolve escalated issues.• Investigate potential overpayments, refunds, subrogation, and TPA claims; escalate suspected fraud or abuse cases to Special Investigations Unit (SIU) as required. • Maintain HIPAA-compliant documentation and audit-ready case notes to support quality reviews, regulatory audits, and process improvements. • Contribute to knowledge-base updates and workflow enhancements, helping streamline claims processes and improve first-pass accuracy.