CareFirst Careers

Claims Supervisor II (DC Medicaid)

Resp & Qualifications

POSITION OVERVIEW

The Claims Operations Supervisor oversees claims processing, inquiries and resolution for the Health Plan. This role oversees claims processing vendors and claims resolution staff, reviewing and adjudicating claims based on provider and health plan contractual agreements and claims processing guidelines.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Oversees and manages the claims processing vendors to meet contracted response times. Oversees and manages internal Claims Resolution staff.
  • Performs regular claims pre-payment auditing.
  • Resolves internal and external day-to-day claims issues, including provider claims inquiries that need to be escalated from Enrollee Services or any other department.
  • Participates in regular claims discussions with key providers, providing denial analysis reporting and training.
  • Assists with special claims projects as needed.
  • Regularly works with the claims processing vendors to track production, error trending, and develop workflow procedures.
  • Assist in backlog reduction, resolving claim issues, and interdepartmental communication to expedite claim handling. Provide needed research to the Provider Appeals and Reconsideration teams.
  • Manages internal claims queues to ensure meeting all key performance indicators.
  • Demonstrated ability to work independently and establish and accomplish team goals. Investigative, decision-making, problem solving, interpersonal, and organizational skills.
  • Manages and ensures compliance with all internal processes and procedures to ensure activities are handled in accordance with departmental and company policies and procedures.

QUALIFICATIONS

  • A minimum of 3-5 years of previous Claims Processing Management experience required.
  • One (1) year experience in MCO service setting preferred.

EDUCATION/CERTIFICATIONS

  • Associates Degree in Business Administration or related field.

Department

Department:DC Medicaid - Claims

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: 4/14/21

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

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