Senior Claims Specialist
Blue Cross and Blue Shield of North Carolina•Remote Flex - North Carolina, NC
•$45,761 - $73,217•Hybrid
About The Position
The Claims Operations Expert is a subject matter expert that enables accelerated claims resolution and production support to manage inventory. Resolve escalated claims from less experienced team members following the formal escalation protocol. Manage work production schedule to balance provider segment preference and staff availability. Identify and resolve errors on custom or special project claims.
Requirements
- High school diploma or GED
- 5+ years of experience in related field.
Nice To Haves
- Claims Analysis
- Claims Management
- Claims Operations
- Claims Processing
- Claims Resolution
- Claims Support
- Health Insurance Portability & Accountability Act (HIPAA)
- Insurance
- Insurance Claim Handling
- Insurance Claims Investigations
- Insurance Procedures
- Medical Claims
- People Management
- Workflow Management
Responsibilities
- Serve as a subject matter expert for employees’ inquiries around work process, procedures, products, policies, etc.
- Process variety of customer transactions that may include non-routine suspended claims, inquiries, adjustments, and correspondence for any business segment
- Contribute in sessions to discuss claims processing workflow and make improvement suggestion to speed up overall claims quality and lead time
- Identify problems, gaps or inconsistencies in workflows and processes; recommend updates, alternatives and/or solutions
- Assist training team in development of claims production staff to be customer centric, cross functional, data driven personnel
- Support Provider Services in resolving immediate issues directly impacting provider financial well being
- Review claims for possible “fraud” and identify root cause by conducting forensic analysis to the problem
- Serve as subject matter expert for project, testing, and validation of claims work processes and procedures
- Communicate with Customer Service and Provider Services to understand key focus of service segment
- Act as a point of contact for NCQA and NCDOI for compliance
- Act as a point of contact for internal and/or external audits and projects as necessary; assist in planning, scoping, testing, training and implementation.
- Identify and document escalated, recurring or complex system and process problems.
- Interface with project teams to resolve these complex issues
Benefits
- Annual Incentive Bonus
- 401(k) with employer match
- Paid Time Off (PTO)
- competitive health benefits
- wellness programs
- two well-being days
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
