Job Description
Resp & Qualifications
PURPOSE:
Investigate and perform adjustment of highly 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. Perform as a team leader to lower-level Claims adjusters.
ESSENTIAL FUNCTIONS:
- Proactively investigate and perform highly complex adjustment of claims. Ensure claims are handled within authority limits, and in line with standard procedures and guidelines.
- Serve as the primary resource for assisting the Supervisor with training new adjusters and developing Adjusters Is and IIs. Identify problems or trends related to adjustments performed. Initiate problem reports for corrective action.
- Assist with customer service phone calls as needed to ensure all corporate goals are met.
- Improves claims adjustment job knowledge by attending training sessions.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS:
Education Level: High School Diploma or GED.
Experience: 7 years' claims experience and complete understanding of all systems, policies and procedures.
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.
Salary Range: $43,272 - $79,332
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Commercial Medical Claims Oper
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.
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
Resp & Qualifications
PURPOSE:
Investigate and perform adjustment of highly 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. Perform as a team leader to lower-level Claims adjusters.
ESSENTIAL FUNCTIONS:
- Proactively investigate and perform highly complex adjustment of claims. Ensure claims are handled within authority limits, and in line with standard procedures and guidelines.
- Serve as the primary resource for assisting the Supervisor with training new adjusters and developing Adjusters Is and IIs. Identify problems or trends related to adjustments performed. Initiate problem reports for corrective action.
- Assist with customer service phone calls as needed to ensure all corporate goals are met.
- Improves claims adjustment job knowledge by attending training sessions.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS:
Education Level: High School Diploma or GED.
Experience: 7 years' claims experience and complete understanding of all systems, policies and procedures.
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.
Salary Range: $43,272 - $79,332
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Commercial Medical Claims Oper
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.
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
About CareFirst BlueCross BlueShield
Named by the Ethisphere Institute as one of the “World’s Most Ethical Companies” for 10 consecutive years.
CareFirst. It’s not just our name. It’s our promise. Over 3.5 million people trust us with their healthcare needs, and we take this responsibility seriously.
Our vision for healthcare is clear. Quality care should be easy to afford, easy to use and available to everyone. And what we’re building for you is exactly what we expect for ourselves and those we love.
Every day, we make a meaningful difference in the communities where we live and work. We solve real problems for the people we serve with equal parts empathy and urgency—simplifying the complex, delivering tailored solutions and stepping forward with new ideas.
RECRUITMENT FRAUD NOTICE: CareFirst is aware of an increase in fraudulent job offers being made on behalf of our recruitment team. Legitimate CareFirst recruiters will always contact you from an email address ending in “@carefirst.com” and will never ask for a payment in exchange for a job opportunity or ask you to submit sensitive personal information via email, phone, or text.
COVID-19 VACCINATION NOTICE: As a leading healthcare organization, it is our responsibility to do our part to help end this pandemic and protect the health and well-being of our members, workforce, communities, businesses and partners. Our recruiters continue to fill open positions. Interviews and other processes are being modified to protect the safety of our candidates and team members. Effective November 1, 2021, COVID-19 full vaccination is required for all employees, including those who work remotely today or in the future. CareFirst will comply with all state and local laws regarding vaccine mandates. Medical and religious exemptions will be made where appropriate using our standard vaccine exemption processes.
Independent licensee of BCBSA.
