Job Description
We're hiring an Operations Specialist to join the Behavioral Health Care Navigation Team! You will be responsible for the resolution of inquiries and/or activities which may include claims, plan policies, products, rates, membership, enrollment, underwriting, direct sales and/or program engagement. The Operations Specialist may also provide cross-functional support for operational functions, which may include one-on-one training, auditing, fulfillment, and/or root cause analysis.What You'll Do
Identify and document escalated, recurring or complex system, process and workflow problems; identify trends, recommend solutions/alternatives and work to resolve issues.
Serve as a subject matter expert for employees’ inquiries and internal/external audits/projects around work process, procedures, products, and policies and provide support, testing, coaching or first level escalation, and research support as needed. Provide cross functional support and departmental expertise to varied internal stakeholders.
Responsible for departmental reporting, tracking and/or data analysis as needed.
Perform quality reviews of inquiries to determine the accuracy of information provided and ensure employees are functioning at the expected level of service to enhance customer interaction. Communicate the results of the reviews to improve individual and overall performance and make recommendations for coaching and training as necessary.
Process a variety of transactions that may include suspended claims, inquiries, adjustments, and/or correspondence.
Determine benefit eligibility on suspended claims for specific products by utilizing medical records, certificate/benefit provisions, and clinical knowledge.
Act as a point of contact for compliance and communicate compliance needs to management staff.
Make direct high volume outreach calls to targeted members utilizing effective engagement strategies and soft sales techniques to respectfully encourage members to engage in Case Management or Disease Management services. May place outbound calls to various providers, customers or other outside contacts.
Coach, educate and guide members in case management and health program participation to increase enrollment and drive positive health outcomes for our members.
May include coordinating relevant mailings of educational or other company materials to members.
May support clinical staff through referrals, mailbox management, work assignment and relevant documentation.
May assist in the review and update of SOPs for Membership and key business partners.
May handle more complex problems of eligibility and documentation with producers. May provide additional information to underwriting staff when submitting referrals for exception consideration.
What You Bring
High school diploma or GED
3+ years of experience in related field
Bonus Points (preferred qualifications)
Experience in Behavioral Health preferred
Prior customer service experience
Ability to work independently; self-driven
Strong team player
Solid organizational skills
What You'll Get
Where You’ll Work
Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused.
In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.
Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
Skills
Case Management, Customer Service, Documentations, Enrollment Management, Insurance Eligibility Verification, Medicaid Documentation, Operations Support, People Management, Process Improvements, Workflow Management_____________________________________________________________________
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.