Operations Specialist

Visa Hunt; United States; Hybrid; USD 42,000 - 67,000; Full time

Job summary

Blue Cross NC is seeking an Operations Specialist to join the Quality, Health Engagement, and Risk Adjustment Team. The role focuses on supporting health plan members in Medicare Advantage and ACA populations, guiding them to PCPs, and helping them navigate benefits to improve health outcomes.

Responsibilities include outreach to providers and members, data analysis, and maintaining confidentiality. Hybrid-flex work model with remote options and in-person collaboration is available.

Qualifications

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

Responsibilities

• Provide cross-functional support for operational and healthcare functions to address care gaps.
• Guiding members to PCPs and advising on benefits to support health.
• Perform outbound calls to providers, members, and vendors to increase health behavior participation.
• Engage members to utilize available benefits and health services.
• Maintain member confidentiality per HIPAA guidelines.
• Coach and guide members in health program participation and preventive care tactics.
• Provide first-level escalation and research support as needed.
• Document processes, procedures, and maintain accurate records.
• Prepare reports and conduct data analysis as assigned.

Skills

Case Management

Customer Service

Enrollment Management

Insurance Eligibility Verification

Medicaid Documentation

Operations Support

People Management

Process Improvements

Workflow Management

Education

High school diploma or GED

Tools

Facets

Genesys

Salesforce

Blue Connect

Microsoft Excel

Job description

Job Description

We’re hiring an Operations Specialist to join the Quality, Health Engagement, and Risk Adjustment Team! This individual will provide cross-functional and cross-team support for operational and/or healthcare functions supporting members in the Medicare Advantage and ACA populations and other LOBs as assigned, to ensure Quality and Risk Adjustment care gaps are addressed and closed by guiding the member to a PCP, advising of available benefits in support of the member’s health, and providing assistance with navigating these benefits if needed.

What You’ll Do

• Perform at the expected level of service to enhance customer interaction and experience.

• Provide regular communication to leadership and other team members on the results of member and/or provider engagements including the potential to participate in regular meetings with key stakeholders and members of upper management.

• Perform outreach based on assignments received through various methods, including outbound calls to various providers, members, vendors, or other outside contacts to increase health behavior participation and drive positive health outcomes for our members.

• Make direct calls to members using effective engagement strategies to respectfully encourage members to utilize available benefits in support of member health behavior participation.

• Maintain member confidentiality per HIPAA compliance guidelines.

• Coach, educate and guide members in health program participation and preventive care tactics.

• May support other team members through referrals, mailbox management, work assignment and relevant documentation.

• Service as the subject matter expert around work process, procedures, products, and policies and provide support, first level escalation, and research support as needed.

• May assist in the review and updating of existing and creation of new processes & procedures.

• Provide cross functional support and departmental expertise to varied internal stakeholders.

• Responsible for maintaining reports, tracking and/or data analysis as assigned or as needed.

• Performs other tasks as assigned by leadership.

What You Bring

• High school diploma or GED

• 3+ years of experience in related field.

Bonus Points (Preferred qualifications)

• Experience working with operational healthcare systems is highly preferred.

Highly Preferred Systems Experience:

• Facets – Experience navigating member records, eligibility, benefits, and healthcare-related information.

• Genesys – Proficiency in call management, queue monitoring, outbound and inbound call activities, wrap-up documentation, and performance metrics.

• Salesforce – Experience documenting member interactions, managing cases, tracking outreach activities, and maintaining accurate records.

• Blue Connect – Ability to navigate member-facing healthcare tools and resources to support member inquiries and engagement activities.

• Microsoft Excel – Strong working knowledge of Excel, including data entry, filtering, sorting, reporting spreadsheets, and basic data analysis.

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

Case Management, Customer Service, Documentations, Enrollment Management, Insurance Eligibility Verification, Medicaid Documentation, Operations Support, People Management, Process Improvements, Workflow Management