The Claims and Customer Advocate is responsible for providing accurate and timely customer service and claims processing to members and providers. This position must meet and maintain departmental standards for timeliness and accuracy including Member Touchpoint Measures (MTM), First Call Resolution (FCR), Federal Employee Program (FEP)/Office of Personnel Management (OPM) measures, BlueCard measures, and Group Performance Guarantees.Essential Functions
- Provides assistance, service and education to all internal and external members, providers, and customers. Ensure accuracy and timeliness in responding to a variety of inquiries.
- Process and resolve customer issues with varying complexities, which may include system updates and/or claims research.
- Strives to understand any claims inquiry through reasoning, plus research via a variety of online and reference tools.
- Determines appropriate action necessary and documents this process appropriately until inquiry is fully resolved.
- Reviews each claim to make the appropriate determination on the next course of action. Pays and/or adjusts claims which can then be processed, determines claims situations that need to be transferred or rejects claims that cannot be processed or are contract exclusions.
Knowledge, Skills and Abilities
- Utilizes and reviews/works a variety of aged reports, medical notes/forms, faxed information, and voicemails to make additional determination on claims for further processing efforts and handles member/provider letters and appeals.
Attention to Detail and Accuracy
Required: High School Diploma/GED
Preferred: High School Diploma/GED
Field(s) of Study: N/AExperience Requirements
Required: Minimum of 1 Year
Preferred: Minimum of 2 Years
Experience Details: Minimum of 1 year of customer service, office-related, insurance, healthcare or related experience is required.Certification, Licensures& Registration Requirements
Title: N/AEquivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standardsOther Information
State or Agency: N/A
Job Posting Policy 6.05
New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.Equal Opportunity Employment
Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.
For questions, please email ...@bcbsnd.com
This job posting will be closed 3/25/2019 at 8:00AM CST. No further applications will be considered.
Associated topics: adjuster, auto, automobile, bodily, casualty, claim investigator, insurance examiner, insurance investigator, investigation, title examiner