Resp & Qualifications
Under the direction of the Supervisor, Full Service, the essential duties and responsibilities include, but are not limited to, the following:
1. The incumbent uses knowledge of products and the contractual provisions that govern administration to provide client education, to interpret contract language to clients for the purpose of providing benefit utilization and limitations, to determine need for managed care initiatives, and to administer all types of service to a policyholder within a business segment through face-to-face interactions, telephone communication, or written correspondence and claims adjudication. Documents all client interactions according to established procedures.
2. Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, paykey, medical policy, contracts, and policy and procedures. Researches, investigates and resolves pends created by the processing system, determining the reason for the pend. Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.
3. To effectively interact with clients, the incumbent must develop and apply an expert ability to analyze client need by current product mix, risk assessment, and revenue impact. Responds to telephone inquiries and written inquiries from subscribers, group administrators, providers, brokers, medical professionals, and internal personnel regarding contracts, benefits, and claims processing.
4. Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other BCBS Plans. Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.
5. Learns and administers all phases of client account management and the management of care cost dollars through the identification of pre-existing conditions, knowledge of policies and riders, identification of other insurance and coordination of benefits, identification of benefit exclusions, identification of falsified application information, determination of the need or opportunity for case management, and identification of fraudulent billing practices, terminal liability, and other party liability.
6. Learns to access information from BCBSMD automated systems, and by telephone and written inquiry with clients, providers, brokers, group administrators, providers, other Blues plans, and other insurance companies. Responds to client inquiries (written, by phone, or in person) about benefits or disputes about adjudication decisions, assures accuracy of the decision, and educates the client on the methods applied.
7. To effectively administer service, the incumbent must utilize a range of automated systems including but not limited to EAB, CBS, Suspense, CIA, BCIQ, BCXF, GMRI, PV40, PV00, MPPC, CARE, MZ00, NASCO, ITS, Latron, and MBO1.
8. Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.
Required: Position requires performance in either service or claims for a minimum of 18 months at a meets standard level or above. Must have 2 years of previous customer service and/or claims experience. Additional required experience includes use of automated systems, PC or CRT proficiency, excellent oral and written communication skills, time and organizational management, and successful project management. Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred. Exposure to project management and supervision is helpful. A Bachelor Degree is preferred.
Must develop and demonstrate proven application of a minimum of one specialized function at a meets standards level or above according to productivity and service standards established for the department in the first year. Must also demonstrate a baseline working knowledge and application of at least one additional technical area at a meets standards or above level within the second year.
As a level I Claims Representative, the incumbent must become proficient in coding and batch for paper claims for the following services: medical office, routine/non-routine, including well baby; allergy services; non-surgical injections; diagnostic lab, x-ray machine, professional component/full biller; physical, speech, and occupational therapy, emergency accident and S&S; second surgical opinion; and Medicare supplemental.
As a level I Service Representative, the incumbent must become proficient in routine benefits, claims, and general inquiries. They should also have a general knowledge of the following: systems; benefits; contracts/products; functions of other departments in the company; standard operating procedures; claims status; NMIS standards; CIA and follow-up to a customer inquiry; QLGS; organizational skills; paper flow. To be successful, the incumbent must learn and apply basic business and technical skills and contribute to the overall success of the team and department.
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
Please apply before: 3/5/2020
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.
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