The Claims Operations Expert is a subject matter expert that enables accelerated claims resolution and production support to manage inventory. Resolve escalated claims from less experienced team members following the formal escalation protocol. Manage work production schedule to balance provider segment preference and staff availability. Identify and resolve errors on custom or special project claims.What You'll DoServe as a subject matter expert for employees’ inquiries around work process, procedures, products, policies, etc. Process variety of customer transactions that may include non-routine suspended claims, inquiries, adjustments, and correspondence for any business segmentContribute in sessions to discuss claims processing workflow and make improvement suggestion to speed up overall claims quality and lead timeIdentify problems, gaps or inconsistencies in workflows and processes; recommend updates, alternatives and/or solutionsAssist training team in development of claims production staff to be customer centric, cross functional, data driven personnel Support Provider Services in resolving immediate issues directly impacting provider financial well being Review claims for possible “fraud” and identify root cause by conducting forensic analysis to the problemServe as subject matter expert for project, testing, and validation of claims work processes and procedures Communicate with Customer Service and Provider Services to understand key focus of service segmentAct as a point of contact for NCQA and NCDOI for complianceAct as a point of contact for internal and/or external audits and projects as necessary; assist in planning, scoping, testing, training and implementation.Identify and document escalated, recurring or complex system and process problems. Interface with project teams to resolve these complex issuesWhat You'll BringHigh school diploma or GED5+ years of experience in related field.Bonus PointsExperience processing claims end-to-end is strongly preferredExperience in Health Insurance claims processing.Strong analytical and research skillsFacets knowledge is a plusWhat You’ll GetThe opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the communityWork-life balance, flexibility, and the autonomy to do great workMedical, dental, and vision coverage along with numerous health and wellness programsParental leave and support plus adoption and surrogacy assistanceCareer development programs and tuition reimbursement for continued education401k match including an annual company contributionWhere You’ll WorkOur 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 RangeAt 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. $45,761.00 - $73,217.00About UsIt'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 StatesWe 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 AccommodationsBlue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at HR.Staffing@bcbsnc.com.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
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