Claims Representative

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 Bring

• High school diploma or GED

• 0-2 years of experience in related field.

Bonus Points (Preferred qualifications)

• Data entry experience is a plus.

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 Processing, Claims Resolution, Claims Review, Customer Service, Documentations, Insurance, Insurance Claims, Medical Claims Processing, Medicare, Patient Care, Policy Knowledge, Process Improvements

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JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected].