Claims Specialist

Blue Cross NC

. Review and timely adjudicate claims in accordance with contractual benefits and health care policies .

Posted 9/24/2026full-timeRemote • North Carolina • United StatesMid-LevelSenior💰 $41,600 - $66,561 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in claims adjudication, processing, and resolution within health insurance operations, ensuring compliance with policies and performance standards while driving efficiency and continuous improvement.

Highest-signal resume keywords

Claims AdjudicationHealth Insurance Claims OperationsClaims ProcessingFraud DetectionContinuous Improvement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ManagementClaims Payment ProcessingBenefit Eligibility ReviewClaims History AnalysisSuspended Claim ResolutionQuality Standards CompliancePerformance MonitoringDocumentation of System IssuesTailored Solutions DevelopmentCoordination with Insurance Carriers

Soft Skills

Customer Service CommunicationProblem SolvingCollaborationAttention to DetailAdaptability

Industry Keywords

Health Care PoliciesInsurance ClaimsBCBSNCMedicareSpecial Investigations Unit

About the role

Key responsibilities & impact

Review and timely adjudicate claims in accordance with contractual benefits and health care policies
Administer claims and manage daily work queues
Process, adjust, or update moderate to complex claims payments and payment errors
Respond to inquiries regarding claims payments from customer service professionals, subscribers, providers, physicians, and other insurance carriers
Meet or exceed established quality and performance standards
Determine suspended claim resolution methods by reviewing benefit eligibility, claims history, and other information
Escalate claims requiring specialized resolution to subject matter experts
Understand business requirements for customer and provider segments and provide tailored solutions
Identify system issues, document them, recommend potential solutions, and refer them to technical staff
Work with Provider Services specialists to deliver tailored services
Review claims for possible fraud and abuse and refer them to the Special Investigations Unit
Drive efficiency and production gains through continuous improvement and share best practices
Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
Represent Claims interests on divisional or enterprise project teams
Monitor claim turnaround times to ensure compliance guidelines and performance guarantees are met

Requirements

What you’ll need

High school diploma or GED
3+ years of experience in related field
At this time, Blue Cross NC will not sponsor employment authorization for this position
Preferred: Experience in health insurance claims operations

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
Paid Time Off (PTO)
Annual Incentive Bonus
Flexible work arrangements
Work-life balance and autonomy