Hybrid-Remote Claims Specialist

Blue Cross and Blue Shield of North Carolina; South Carolina; 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)

Wellness programs

Parental leave and adoption/surrogacy

Job summary

Blue Cross and Blue Shield of North Carolina is seeking a Claims Representative to adjudicate and administer claims in line with contractual benefits. You will manage queues, ensure timely processing, and respond to inquiries from subscribers, providers, and carriers.

The role emphasizes quality, compliance, and potential process improvements within a hybrid work structure. The position requires a high school diploma or GED and 0–2 years of related experience, with data entry as a plus.

Qualifications

• High school diploma or GED required.
• 0–2 years of experience in related field.
• 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 Analysis

Claims Management

Claims Processing

Claims Resolution

Claims Review

Customer Service

Documentation

Insurance

Insurance Claims

Medical Claims Processing

Medicare

Patient Care

Policy Knowledge

Process Improvements

Education

High school diploma or GED

Job description

Blue Cross and Blue Shield of North Carolina is seeking a Claims Representative to adjudicate and administer claims in line with contractual benefits. You will manage queues, ensure timely processing, and respond to inquiries from subscribers, providers, and carriers.

The role emphasizes quality, compliance, and potential process improvements within a hybrid work structure. The position requires a high school diploma or GED and 0–2 years of related experience, with data entry as a plus.