FEP Service Specialist
About The Position
The FEP Service Specialist is responsible for investigating and resolving complex written inquiries and appeals to ensure timely and accurate claims adjudication. This role collaborates across the FEP Business Unit as well as other business partners to identify opportunities for process improvement and provider education, directly contributing to our commitment to service excellence. This role is perfect for a detail-oriented problem-solver who excels at critical thinking and thrives in a collaborative, fast-paced environment. This position is eligible for the following persona(s): eWorker, mobile, resident.
Requirements
- 2+ years of successful experience in a customer service or healthcare operations environment.
- Strong computer skills with proficient knowledge of NASCO (including claims adjudication), Medical Management System (MHK), and other web-based business applications
- Excellent organizational, critical thinking, and problem-solving abilities.
- Strong verbal and written communication skills.
- Demonstrated ability to work independently while also being a flexible, self-motivated team player.
- Adept at giving and receiving feedback in a constructive and positive manner.
- High school diploma or equivalent is required.
Nice To Haves
- Experience with FEP is preferred.
- A college degree or comparable work experience is preferred.
Responsibilities
- Inquiry and Appeals Resolution: Research, analyze, and resolve written provider inquiries and claims appeals with a high degree of accuracy, meeting all timeliness goals
- Claims Adjudication: Navigate a dual-system environment (FEP National, NASCO) to accurately interpret contracts, adjudicate claims, and manage pricing arrangements
- Clinical Case Research: Facilitate research for inquiries requiring medical review by documenting information in the Medical Management System (MHK) and coordinating with RN reviewers
- Risk & Compliance: Proactively identify and mitigate potential risks to ensure Plan compliance and performance by adhering to all internal policies (e.g., BCBSMA payment policy, FAM II, FEP medical policy)
- Service Excellence: Provide exceptional service to both internal and external customers, aiming for first-contact resolution.
- Trend Analysis: Identify trends, errors, and opportunities for process improvements that increase efficiency and satisfaction for members, providers, and accounts.
- Team Contribution: Actively contribute to team efforts to meet and exceed service, production, and quality standards. Participate in cross-functional teams to help achieve FEP Plan Incentive Program (PIP) goals.
- Caseload Management: Skillfully prioritize and manage your caseload to meet and exceed production goals for inventory levels.
Benefits
- We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
1,001-5,000 employees
