Claims Specialist

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

📋 Description

• Evaluate and promptly adjudicate claims in line with contractual benefits and health care policies.

• Manage claims administration and oversee daily work queues.

• Process, adjust, or update claims payments and rectify payment errors that are moderate to complex.

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

• Achieve or surpass set quality and performance benchmarks.

• Identify resolution strategies for suspended claims by analyzing benefit eligibility, claims history, and other relevant data.

• Refer claims needing specialized resolution to subject matter experts.

• Comprehend business needs for customer and provider segments and offer customized solutions.

• Detect system issues, document them, suggest potential fixes, and communicate with technical teams.

• Collaborate with Provider Services specialists to provide tailored services.

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

• Enhance efficiency and production by implementing continuous improvement practices and sharing best practices.

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

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

• Track claim turnaround times to ensure adherence to compliance guidelines and performance commitments.

⛳️ Requirements

• High school diploma or GED.

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

• At this time, Blue Cross NC will not provide employment authorization sponsorship for this role.

• Preferred: Experience in health insurance claims operations.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Health and wellness programs.

• Parental leave and support.

• Assistance with adoption and surrogacy.

• Career development opportunities.

• Tuition reimbursement for ongoing education.

• 401k matching along with an annual company contribution.

• Paid Time Off (PTO).

• Annual incentive bonuses.

• Flexible work arrangements.

• Emphasis on work-life balance and autonomy.