Resp & Qualifications
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
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.
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.
Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
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.
Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Looks for and takes advantage of opportunities; Asks for and offers help when needed.
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.
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
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.
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