Claims Representative

This is a fully remote position, open to applicants in North Carolina, +2 more states.

📋 Description

• Evaluate and promptly adjudicate claims

• Administer claims in accordance with contractual benefits and healthcare policies

• Oversee daily work queues and ensure the quality of processed claims

• Guarantee the final resolution of claims

• Track claim turnaround times to comply with guidelines and performance commitments

• Process, adjust, or update standard claims payments and rectify payment errors

• Address inquiries from Core Service, subscribers, providers, physicians, and other insurance carriers concerning claims payments

• Determine methods for resolving suspended claims by assessing benefit eligibility, claims history, and other relevant information

• Identify system issues, document concerns, suggest potential solutions, refer matters to technical staff, and follow up on resolutions

• Recognize and evaluate opportunities to enhance BCBSNC processes, policies, and services

• Collaborate with other insurance carriers and Medicare to establish BCBSNC payment responsibilities

• Examine claims for potential fraud and abuse and escalate them to the Special Investigations Unit

⛳️ Requirements

• High school diploma or GED required

• 0-2 years of experience in a related field

• Data entry experience is advantageous

• Familiarity with claims adjudication, claims analysis, claims management, claims processing, claims resolution, claims review, insurance claims, medical claims processing, Medicare, policy knowledge, and process enhancements

• Strong customer service skills

• Proficient documentation skills

🏝️ Benefits

• Medical, dental, and vision coverage

• Health and wellness programs

• Parental leave and support

• Adoption and surrogacy assistance

• Career development programs

• Tuition reimbursement for ongoing education

• 401(k) match with an annual company contribution

• Paid Time Off (PTO)

• Annual Incentive Bonus

• Flexible work arrangements

• Remote work with occasional in-office visits each year for Remote Flex roles