QUALIFICATIONS:

Education Level: High School Diploma or GED
Experience: 3 years claims experience and complete understanding of all systems, policies and procedures.

PREFERRED QUALIFICATIONS:

Above Target performance rating preferable.
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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: $36,144 - $66,264
  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 responsibilites 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
  Facets Coordination of Benefit
  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.
  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 health care programs.

PURPOSE:

Investigate and perform adjustment of 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 claims. Ensure claims are handled within authority limits, and in line with standard procedures and guidelines.
• Updates claims audit records by entering, verifying, and securing data.
• Settle standard/complex claims through payment or denial.
• Provides claims audit information and reports by collecting, analyzing, and summarizing data and trends.Improves claims adjustment job knowledge by attending training sessions.