Claims Specialist

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Evaluate and promptly adjudicate claims in alignment with contractual benefits and healthcare policies.

• Oversee daily work queues, the quality of processed claims, and their final resolutions.

• Track claim turnaround times to ensure compliance with guidelines and performance metrics.

• Process, adjust, or modify moderate to complex claims payments and rectify payment errors.

• Address inquiries about claims payments from customer service representatives, subscribers, providers, physicians, and other insurance companies.

• Achieve or surpass established quality and performance benchmarks.

• Determine resolution strategies for suspended claims by analyzing benefit eligibility, claims history, and additional information.

• Elevate claims that require specialized resolution to subject matter experts.

• Identify system problems, propose potential solutions, and escalate issues to technical staff.

• Collaborate with Provider Services specialists to offer customized provider services.

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

• Promote efficiency and production improvements through continuous enhancement and claims expertise.

• Coordinate with other insurance providers and Medicare to ascertain BCBSNC payment responsibilities.

• Advocate for Claims interests on divisional or enterprise project teams.

⛳️ Requirements

• A high school diploma or GED is required.

• Minimum of 3 years of experience in a related field.

• Currently, Blue Cross NC will not sponsor employment authorization for this role.

• Experience with health insurance claims is a bonus.

• Familiarity with Facets claims is a bonus.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Health and wellness initiatives.

• Support for parental leave.

• Assistance with adoption and surrogacy.

• Programs for career development.

• Tuition reimbursement for ongoing education.

• 401k matching with an annual company contribution.

• Paid Time Off (PTO).

• Annual incentive bonus.

• A focus on work-life balance, flexibility, and autonomy.

• Opportunity for remote work, with occasional in-office visits each year for significant occasions.