Resp & Qualifications
PURPOSE:
Investigate and perform adjustment of complex claims and ensure that claims are handled properly within authority limits, and in line with standard procedures and guidelines. Verifies insurance claims by reviewing claims requirements; examining documentation and calculations; highlighting and summarizing out-of-line situations; recommending changes in operating processes; completing reports, logs, and audit records.
ESSENTIAL FUNCTIONS:
Proactively investigate and perform adjustments of complex claims. Ensure claims are handled within authority limits, and in line with standard procedures and guidelines.
Establishes insurance losses by evaluating reports and documentation. Documents insurance claim actions by completing logs and files; collecting, analyzing, and summarizing information in reports.
Settles insurance claims by approving or denying claims and partnering with supervisor on progress towards claim settlement.
Improves claims adjustment job knowledge by attending training sessions.
QUALIFICATIONS:
Education Level: High School Diploma or GED.
Experience: 5 years years claims experience and complete understanding of all systems, policies and procedures.
Preferred Qualifications:
Prior performance review achievement of Above Target.
Knowledge, Skills and Abilities (KSAs)
- Ability to analyze information gathered from investigation.
- Excellent communication skills both written and verbal.
- Ability to recognize, analyze, and solve a variety of problems.
- Skill in completing assignments accurately with attention to detail.
- 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.
Department
Department: MD 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
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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