Claims Representative

Blue Cross and Blue Shield of North Carolina; North Carolina; Hybrid; USD 42,000 - 67,000; Full time

Benefits offered by this job

Health coverage

Work-life balance

Parental leave

Tuition reimbursement

401k match

Job summary

Blue Cross NC is seeking a Claims Representative to review and adjudicate claims, administer them per contractual benefits and health care policies, and manage daily work queues. You will monitor claim turnaround times to ensure compliance and performance guarantees.

This hybrid-flex role lets you work in the Durham area with remote options, collaborating with providers, members, and carriers. You’ll contribute to fraud review, process improvements, and service quality while growing through

Qualifications

• High school diploma or GED.
• 0-2 years of experience in related field. Bonus Points (Preferred qualifications) Data entry experience is a plus.

Responsibilities

• Process, adjust or update various routine claims payments and payment errors for singular business segment and/or claims-provider type
• Respond promptly and accurately to inquiries from Core Service, subscribers, providers, physicians and other insurance carriers regarding claims payments
• Meet or exceed established quality and performance standards
• Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information
• Identify system problems, including documentation of the issue, recommendation of potential solutions, referral to appropriate technical staff and follow-up to ensure resolution
• Assist management by identifying and analyzing opportunities for improvements in BCBSNC processes, policies and services
• May coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
• Review claims for possible fraud and abuse and send to Special Investigations Unit for additional investigation

Skills

Claims Adjudication

Claims Processing

Customer Service

Documentation

Medicare

Policy Knowledge

Process Improvements

Claims Review

Claims Analysis

Job description

Job Description

We're hiring a Claims Representative to join the Claims Team! Under direct supervision, the Claims Representative reviews and timely adjudicates claims and administers them in accordance with contractual benefits and health care policies. The Claims Representative is responsible for managing daily work queues, quality of claims processed and final resolution. Also monitors claim turnaround times to assure all compliance guidelines are met as well as performance guarantees. Claims reviewed are for singular business segment and/or singular claims-provider type.

What You'll Do

• Process, adjust or update various routine claims payments and payment errors for singular business segment and/or claims-provider type
• Respond promptly and accurately to inquiries from Core Service, subscribers, providers, physicians and other insurance carriers regarding claims payments
• Meet or exceed established quality and performance standards
• Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information
• Identify system problems, including documentation of the issue, recommendation of potential solutions, referral to appropriate technical staff and follow-up to ensure resolution
• Assist management by identifying and analyzing opportunities for improvements in BCBSNC processes, policies and services
• May coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
• Review claims for possible fraud and abuse and send to Special Investigations Unit for additional investigation

What You'll Get

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• 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 including an annual company contribution

Learn more

Where You'll Work

Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that’s flexible, connected, and future focused. In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

$41,600.00 - $66,561.00

Skills

• Claims Adjudication
• Claims Analysis
• Claims Management
• Claims Processing
• Claims Resolution
• Claims Review
• Customer Service
• Documentations
• Insurance
• Insurance Claims
• Medical Claims Processing
• Medicare
• Patient Care
• Policy Knowledge
• Process Improvements

What You Bring

• High school diploma or GED
• 0-2 years of experience in related field. Bonus Points (Preferred qualifications) Data entry experience is a plus.

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview for English or Visión General de E-Verify for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at [e-mail].

Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.