The primary function of the role is to apply specialized knowledge and skills as an exempt individual contributor. The incumbent will utilize discipline-specific expertise to analyze data, document results and provide recommendations in support of business decisions as well as continuous improvement opportunities. In addition, the role will provide technical support and guidance to Service Advocates, assist the supervisor with daily activities and oversee direct reports in absence of the supervisor.
Roles in the Claims organization review and adjudicate claims; determine whether to enter, return, deny or pay claims following policies and procedures; process subrogation, workers' compensation and other claims when third party liability may exist; recover overpayments, and answer inquiries from other departments, insurance adjustors, attorneys and members. The work is guided by the practices, procedures, general work instructions and supervision of progress and results.
The essential functions listed represent the major duties of this role, additional duties may be assigned.
Support continuous improvement efforts as identified from various sources including but not limited to tracking and trending audits from various feedback sources and Individual Quality Team Auditors. Analyze data, identify gaps and improve opportunities in cue cards or by providing formal and ad-hoc training.
Serve as subject matter expert to EL&D training curriculum and provide formal training for Service Advocates
Monitor and evaluate the effectiveness of solutions, policies, practices and processes to ensure continuous improvement, good member experience and adherence to business requirements. Recommend improvements to achieve and deliver high quality, value-added services.
Develop and build internal partnerships to improve communication, coordination, collaboration and effective working relationships within own department, across the Company and external business partners.
Mentor and coach less experienced coworkers on the technical and interpersonal skills needed for effective job performance.
Coordinate, produce, and distribute business documents such as but not limited to cue cards, reports, system and process documentation.
Serve as the primary resource and subject matter expert for leadership for the immediate resolution of the highest level of escalation or sensitive member/provider complaints and issues.
Representative in departmental meetings, workgroups or initiatives, assignment of inventory, performance management and time and labor updates in supervisor absence.
Required Work Experience
2 years of Health Insurance Customer Service and/or Claims processing experience.
Bachelor's degree in related field or an equivalent combination of education and experience.
Basic Micro Soft Word, Excel, PowerPoint and Outlook.
Florida Blue Training Certification (Certification obtained within 90 days of accepting the role)
Demonstrates Flexibility and Supports Change.
Ability to provide feedback to elevate the performance level of an individual or team.
Must pass highest level School required background check and complete finger printing requirements.
Preferred Work Experience
1 years Leadership experience.
1 years of Florida Blue Claims experience.
Knowledge of Florida Blue Health and ancillary products and systems.
1 years of delivering training and/or teaching high school students.
We are an Equal Opportunity Employer/Protected Veteran/Disabled.
Blue Cross Blue Shield Of Florida