Claims Specialist

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

Benefits offered by this job

Medical, dental, and vision coverage

Parental leave

Tuition reimbursement

401k match

Job summary

Blue Cross and Blue Shield of North Carolina is hiring a Claims Specialist to adjudicate and process claims with moderate supervision. You will manage daily work queues, ensure timely resolutions, and monitor claim turnaround to meet compliance and performance standards.

You’ll respond to inquiries from customers, providers, and insurers while identifying issues, potential improvements, and opportunities for fraud detection.

Qualifications

• High school diploma or GED required.
• 3+ years of experience in related field.
• Blue Cross NC will not sponsor employment authorization for this position.

Responsibilities

• Process, adjust or update various moderate to complex claims payments for any business segment and/or claims-provider type.
• Respond promptly and accurately to inquiries from Customer Service Professionals, 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.
• Escalate claims requiring specialized resolution to subject matter experts based on department policies and guidelines to ensure the resolution.
• Understand business requirement for the customer and provider segments with tailored solutions to their needs.
• Identify system issues by documenting the issue, recommend potential solution and refer appropriate technical staff.
• Work with designated Provider Services specialists to deliver services tailored to the provider services.
• Review claims for possible “fraud and abuse” and send to Special Investigations Unit for additional investigation.
• Use continuous improvement and knowledge of claims to drive efficiency and production gains; share best practices.
• Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability.
• Represent Claims interests on divisional or enterprise project teams

Skills

Claims Adjudication

Claims Analysis

Claims Management

Claims Processing

Claims Resolution

Documentation

Health Insurance Processing

Insurance Claims Investigations

Medical Claims Processing

Process Improvements

Workload Management

Education

High school diploma or GED

Job description

Job Description We’re hiring a Claims Specialist to join the Claims Operations Team! With moderate supervision, the Claims Specialist reviews and timely adjudicates claims and administers them in accordance with contractual benefits and health care policies. The Claims Specialist drives an end-to-end service model that decreases handoffs and improves ownership across claims life cycle. The role 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 non-routine and are for any business segment and/or multiple claims-provider type. At Blue Cross NC, we’re making health care better for all – by listening deeply, challenging what’s possible, and putting care at the heart of everything we do. Join a purpose driven team where ideas spark change, growth is encouraged, collaboration fuels impact, and you’re supported with the flexibility and trust to do meaningful work.

What You’ll Do

• Process, adjust or update various moderate to complex claims payments and payment errors for any business segment and/or claims-provider type
• Respond promptly and accurately to inquiries from Customer Service Professionals, 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
• Escalate claims requiring specialized resolution to subject matter experts based on department policies and guidelines to ensure the resolution
• Understand business requirement for the customer and provider segments with tailored solutions to their needs
• Identify system issues by documenting the issue, recommend potential solution and refer appropriate technical staff
• Work with designated Provider Services specialists to deliver services tailored to the provider services
• Review claims for possible “fraud and abuse” and send to Special Investigations Unit for additional investigation
• Use continuous improvement and knowledge of claims to drive efficiency and production gains; share best practices
• Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
• Represent Claims interests on divisional or enterprise project teams

What You Bring

• High school diploma or GED 3+ years of experience in related field. At this time, Blue Cross NC will not sponsor employment authorization for this position.

Bonus Points

• Experience in health insurance claims operations

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

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. $41,600.00 - $66,561.00

Skills

• Claims Adjudication, Claims Analysis, Claims Management, Claims Operations, Claims Processing, Claims Resolution, Documentations, Health Insurance Processing, Insurance, Insurance Claim Handling, Insurance Claims, Insurance Claims Investigations, Insurance Claims Processing, Medical Claims Processing, Process Improvements, Workload Management

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, hiring process, or have technical issues that prevent you from completing your application 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