Operations Specialist

Blue Cross and Blue Shield of North Carolina

1d • Hybrid

About The Position

We're hiring an Operations Specialist to join the Behavioral Health Care Navigation Team! You will be responsible for the resolution of inquiries and/or activities which may include claims, plan policies, products, rates, membership, enrollment, underwriting, direct sales and/or program engagement. The Operations Specialist may also provide cross-functional support for operational functions, which may include one-on-one training, auditing, fulfillment, and/or root cause analysis.

Requirements

• High school diploma or GED
• 3+ years of experience in related field

Nice To Haves

• Experience in Behavioral Health preferred
• Prior customer service experience
• Ability to work independently; self-driven
• Strong team player
• Solid organizational skills

Responsibilities

• Identify and document escalated, recurring or complex system, process and workflow problems; identify trends, recommend solutions/alternatives and work to resolve issues.
• Serve as a subject matter expert for employees’ inquiries and internal/external audits/projects around work process, procedures, products, and policies and provide support, testing, coaching or first level escalation, and research support as needed.
• Provide cross functional support and departmental expertise to varied internal stakeholders.
• Responsible for departmental reporting, tracking and/or data analysis as needed.
• Perform quality reviews of inquiries to determine the accuracy of information provided and ensure employees are functioning at the expected level of service to enhance customer interaction.
• Communicate the results of the reviews to improve individual and overall performance and make recommendations for coaching and training as necessary.
• Process a variety of transactions that may include suspended claims, inquiries, adjustments, and/or correspondence.
• Determine benefit eligibility on suspended claims for specific products by utilizing medical records, certificate/benefit provisions, and clinical knowledge.
• Act as a point of contact for compliance and communicate compliance needs to management staff.
• Make direct high volume outreach calls to targeted members utilizing effective engagement strategies and soft sales techniques to respectfully encourage members to engage in Case Management or Disease Management services.
• May place outbound calls to various providers, customers or other outside contacts.
• Coach, educate and guide members in case management and health program participation to increase enrollment and drive positive health outcomes for our members.
• May include coordinating relevant mailings of educational or other company materials to members.
• May support clinical staff through referrals, mailbox management, work assignment and relevant documentation.
• May assist in the review and update of SOPs for Membership and key business partners.
• May handle more complex problems of eligibility and documentation with producers.
• May provide additional information to underwriting staff when submitting referrals for exception consideration.

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match

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