Case Specialist - GAU
Investigate and resolve member and provider complaints, benefits appeals and administrative appeals on all company products. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements. Maintain all appeals documentation according to external agency requirements.
ESSENTIAL JOB FUNCTIONS:
- Investigate and resolve member and provider complaints, benefits appeals, and administrative appeals for all company products. Maintain documentation of cases.
- Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication.
- Assist members gain a better understanding of the plan through education.
- Identify potential quality of care issues; escalate as appropriate.
- Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary.
- Participate in departmental audits in preparation of regulatory site visits.
- Participate in department initiatives and projects.
- Perform other duties as assigned.
Minimum Education and Experience:
- High school degree
- Two to four years experience in a managed care environment
Preferred Education, Additional Qualifications and Experience:
- Proficiency with Microsoft Suite of products; i.e., Word, Excel, PPT, etc
- Prior health insurance industry experience (Customer service, Claims, Systems)
Required Knowledge, Skills, and/or Abilities:
- Knowledge of health insurance laws and regulations
- Working knowledge of Microsoft Office including Excel, and Word
- General computer proficiency
- Written and verbal communications skills
- Good organization skills
- Time management skills
- Detail oriented
- Ability to research and organize data
- Ability to organize work efficiently to meet established time and quality standards
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf to view the "EEO is the Law" poster.
- Pay Type Hourly
- Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, Rhode Island, United States of America