CareFirst Careers

Operations Functional Analyst

Resp & Qualifications

PURPOSE:  The incumbent is responsible for providing analytical support for existing systems as well as participating in the design and implementation of new systems to ensure claims and service applications are operating effectively and efficiently to achieve ASU goals and objectives.  The incumbent will  participate in the analysis of existing business processes and systems to recommend process and system enhancements.  The incumbent may coordinate with or provide consulting services to other CareFirst departments and external entities, such as vendors, consultants, auditors, other BCBS Plans, BCBSA, the FEP Director’s Office, and government agencies such as the Office of Personnel Management. The incumbent is a subject matter expert in support of claims processors, adjustors, customer service representatives, OPL analysts, etc. and provides support to those individuals in conjunction with department supervisors to ensure continuous improvement to job knowledge, quality, and productivity to better serve CareFirst customers

PRINCIPAL ACCOUNTABILITIES:

Under the general supervision of a Manager or above the incumbent’s accountabilities may include, but are not limited to, the following:

  • Provides ongoing internal and external customer support for system questions for customer inquiries and problems impacting claims; serves as subject matter expert for business processes and related systems; coordinating with vendors and other parties as necessary, and tracks them to resolution; develops, documents, and communicates alternative workarounds for system defects until system solutions can be implemented.  Resolves complex claims adjustments involving knowledge of all products and benefits and account arrangements.
  • Defines and documents less complex business and system requirements and provides input to business work papers and specifications; reviews test results; determines if system handled claims as benefit contracts require; ensures that claims are correctly adjudicated as a result of systems fixes.
  • Participates in the analysis of existing business processes and systems to determine human or technical errors.  Conducts research to make recommendations, assist in the preparations for testing, update SOPs and training documents. Assures that all claims related to the error are corrected.
  • Participates in the implementation of new systems initiatives.  Helps to define, document, and validate new business requirements with existing contracts and system requirements.
  • Performs status reporting and writing specifications for ad-hoc report requests.  Acts a special projects person/dedicated processor for sensitive providers/institutions or large-scale claims reprocessing resulting from an audit.  Expands knowledge and skills of CareFirst business processes, quality assurance, and system development methodology.


QUALIFICATION REQUIREMENTS:
Required: This position requires a bachelor’s degree or equivalent work experience.  Must have been a Claims Processor II or above (substitute CSR II or above, Full Service CSR II or above, Adjustor II or above, Quality Assurance Analyst II, E&B Tech II or Sr. OPL Analyst above) for a minimum of 4 years, or 2 years Claims Liaison experience.

Demonstrated systems experience to include: FACETS and/or FLEXX and/or NASCO/and or CARE   experience. Thorough understanding of BCBS claims and service systems and reports is necessary.  Detailed knowledge of benefits packages, membership and claims systems.  Knowledge of administrative and internal procedures is essential, including internal/external  operating policies, business rules by product and platform, medical policy and BCBSA standards, MIA/VBOI regulations and governance, SAS70 and Sarbanes Oxley compliance.

Abilities/Skills: Relevant business and systems subject matter expertise.  Ability to work independently and as part of a team. Excellent interpersonal skills.  Ability to lead problem-solving discussions. Attention to detail and excellent analytical and problem-solving skills.  Excellent written and verbal communication skills.  Excellent organizational skills and ability to set priorities and handle multiple projects concurrently.  Extensive PC skills including Microsoft office software such as Word and Excel.

Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Preferred: SOP writing experience.  Experience with both mainframe and client/server technology.  Training experience.

 

Department

IT & Busi Support Contact Center

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 12/06/2019

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

Learn more about Customer Service & Claims