CareFirst Careers

Claims Resolution Specialist (DC Medicaid)

Resp & Qualifications

POSITION OVERVIEW

The Claims Resolution Specialist will perform in house claims adjudication for complex medical claims. Work with Management to improve processes and quality of data for adjudication purposes. Provide regular reporting to Health Plan leadership and Provider leadership. This role is supporting “Community Health Plan – DC”

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Perform claims adjudication for complex medical claims.
  • Perform regular auditing
  • Schedule regular meetings with key provider groups to provide reporting and work through claim resolution issues
  • Handle provider phone calls and emails regarding claims
  • Generate weekly Claims Resolution reports for management in accordance with schedule set by supervisor.
  • Interfaces with Organization’s personnel to include fellow team members, supervisor, managers and customers while maintaining the integrity of claims.
  • Adheres to all federal laws and company policies regarding confidentiality of privileged patient information.
  • Adheres to company Human Resource policies and understands daily company work requirements.
  • Enhances organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.  

 

QUALIFICATIONS

  • A minimum of three (3) years of medical claims processing experience
  • Managed Care experience heavily preferred

EDUCATION/CERTIFICATIONS

  • High School degree required
  • Medical Billing & Coding Certification
  •  BA/ BS preferred

COMPETENCIES

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical | Collects and researches data; Uses intuition and experience to complement data.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

Project Management | Communicates changes and progress; Completes projects on time and budget.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service | Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.

Interpersonal Skills | Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

Oral Communication | Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

Written Communication | Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.

Quality Management | Demonstrates accuracy and thoroughness.

Diversity | Shows respect and sensitivity for cultural differences; promotes a harassment-free environment.

Ethics | Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

Organizational Support | Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Supports affirmative action and respects diversity.

Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Adapts strategy to changing conditions.

Judgment | Displays willingness to make decisions; Includes appropriate people in decision-making process; makes timely decisions.

Motivation | Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles.

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources.

Professionalism Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions.

Adaptability

 Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

Attendance/Punctuality

 Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

 

Dependability

Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative

Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Looks for and takes advantage of opportunities; Asks for and offers help when needed.

OTHER SKILLS

  • LANGUAGE SKILLS Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.
  • MATHEMATICAL SKILLS Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
  • REASONING ABILITY Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
  • COMPUTER SKILL To perform this job successfully, an individual should have knowledge of ADP (Total Source/ Workforce), Applicant Tracking System, Database software; Outlook; Human Resource systems; Payroll systems; Spreadsheet software and Word Processing software.
  • PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is frequently required to reach with hands and arms. The employee is occasionally required to stand; walk; climb or balance; stoop, kneel or crouch.

The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

WORK ENVIRONMENT | The noise level in the work environment is usually moderate.

#LI-TW1

Department

Department: DC MEDICAID 

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: 6/6/2020

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.

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 Medical Management