Senior Claims Specialist

Job Description

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.

What You'll Do

• 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

What You'll Bring

• High school diploma or GED

• 5+ years of experience in related field.

Bonus Points

• Experience processing claims end-to-end is strongly preferred

• Experience in Health Insurance claims processing.

• Strong analytical and research skills 

• Facets knowledge is a plus

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.
 

$45,761.00 - $73,217.00

Skills

Claims Analysis, Claims Management, Claims Operations, Claims Processing, Claims Resolution, Claims Support, Healthcare Claims Processing, Health Insurance Portability & Accountability Act (HIPAA), Insurance, Insurance Claim Handling, Insurance Claims Investigations, Insurance Claims Processing, Insurance Procedures, Medical Claims, Medical Claims Processing, People Management, Workflow Management

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