Claims Operations Specialist — Hybrid/Remote

Blue Cross NC; United States; Hybrid; USD 42,000 - 67,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k with employer match

Paid Time Off (PTO)

Tuition reimbursement

Parental leave and surrogacy support

Job summary

Blue Cross NC is seeking a Claims Specialist to join the Claims Operations Team. The role, under moderate supervision, reviews and adjudicates claims, ensuring compliance with contractual benefits and health care policies.

It involves managing queues, monitoring turnaround times, and maintaining quality and ownership across the claims lifecycle. You will handle various inquiries from subscribers, providers, and other carriers while aiming for efficient, compliant resolutions.

Qualifications

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

Responsibilities

• Process, adjust or update moderate to complex claims payments for multiple segments.
• Respond promptly to inquiries from customers, providers and insurers.
• Meet or exceed quality and performance standards.
• Determine suspended claim resolution methods based on eligibility and history.
• Escalate specialized cases to subject matter experts per policy.
• Identify system issues and document them with potential remedies.
• Collaborate with Provider Services to deliver tailored services.
• Review claims for potential fraud and refer to investigations.
• Drive efficiency and share best practices across the team.

Skills

Claims adjudication

Claims processing

Healthcare policy knowledge

Customer service

Quality assurance

Attention to detail

Education

High school diploma or GED

Job description

Blue Cross NC is seeking a Claims Specialist to join the Claims Operations Team. The role, under moderate supervision, reviews and adjudicates claims, ensuring compliance with contractual benefits and health care policies.

It involves managing queues, monitoring turnaround times, and maintaining quality and ownership across the claims lifecycle. You will handle various inquiries from subscribers, providers, and other carriers while aiming for efficient, compliant resolutions.