Claims Representative

Blue Cross NC

. Review and timely adjudicate claims .

Posted 9/18/2026full-timeRemote • North Carolina • United StatesJuniorMid-Level💰 $41,600 - $66,561 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims processing, adjudication, and analysis while ensuring compliance with health care policies and contractual benefits. Proficient in identifying process improvement opportunities and resolving claims-related issues effectively.

Highest-signal resume keywords

Claims ProcessingAdjudicationHealth Care PoliciesCustomer Service SkillsMedicare Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ReviewClaims ManagementData EntryClaims ResolutionFraud Detection

Soft Skills

Analytical SkillsProblem-SolvingCommunication Skills

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

InsuranceMedical Claims ProcessingContractual BenefitsCompliance Guidelines

About the role

Key responsibilities & impact

Review and timely adjudicate claims
Administer claims in accordance with contractual benefits and health care policies
Manage daily work queues and claims processing quality
Monitor claim turnaround times for compliance guidelines and performance guarantees
Process, adjust, or update routine claims payments and payment errors
Respond to inquiries from service teams, subscribers, providers, physicians, and other insurance carriers
Determine suspended claim resolution methods by reviewing benefit eligibility, claims history, and other information
Identify system problems, document issues, recommend solutions, refer issues to technical staff, and follow up on resolution
Assist management by identifying and analyzing process, policy, and service improvement opportunities
Coordinate with other insurance carriers and Medicare to determine payment liability
Review claims for possible fraud and abuse and refer them to the Special Investigations Unit

Requirements

What you’ll need

High school diploma or GED
0-2 years of experience in related field
Data entry experience is a plus
Knowledge of contractual benefits and health care policies
Claims processing, adjudication, analysis, management, review, and resolution
Customer service skills
Insurance and medical claims processing knowledge
Medicare knowledge
Ability to identify and document system problems
Ability to analyze process improvement opportunities

Benefits

Comp & perks

Medical, dental, and vision coverage
Health and wellness programs
Parental leave and support
Adoption and surrogacy assistance
Career development programs
Tuition reimbursement for continued education
401k match including an annual company contribution
Annual Incentive Bonus
Paid Time Off (PTO)
Flexible work arrangements
Remote work with a few in-office visits each year for Remote Flex roles