End-to-End Claims Specialist (Hybrid/Remote)

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

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.