Resp & Qualifications

PURPOSE:
The Representative, Member Service I is proficient in routine benefits, claims, and general inquiries. They have a general knowledge of the following: systems, benefits, contracts/products, functions of other departments in the company, standard operating procedures, claims status, enrollment/billing and follow-up to a customer inquiry.

ESSENTIAL FUNCTIONS:

• Answers member inquiries by clarifying desired information; researching, locating, and providing information. Resolves member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems.

• Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures. Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.

• Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other BCBS Plans. Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.

• Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 1 year customer service, claims experience, Inbound Call Center Experience.

Preferred Qualifications:

• Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.

Knowledge, Skills and Abilities (KSAs)

• Self-starter with strong organizational skills and planning skills.
• Ability to maintain effective interpersonal relationships.
• Ability to recognize, analyze, and solve a variety of problems.
• Excellent communication skills both written and verbal.
• Maintains quality customer services by following customer service practices; responding to customer inquiries.
• 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: IT & Business Support Contact Center

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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