Claims Specialist

• 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

• Investigate the origin and cause of homeowner property claims
• Contact insureds, claimants, agents, attorneys, contractors, experts, special investigation units, adjusters and public personnel
• Identify complex issues and seek assistance as needed
• Handle 1st-party and 3rd-party claims under multiple policy types and endorsements
• Conduct on-site inspections and evaluate damages
• Negotiate claims with insureds, claimants, attorneys and public adjusters
• Respond to customer inquiries, make decisions and close files
• Interpret policies, leases, bylaws, declarations, articles and contract coverages
• Provide parties with claim process and status updates
• Answer questions or redirect inquiries to appropriate areas
• Complete other assignments and participate in projects as needed

Property Field Claims Adjuster

• Handle insurance claims in the field under general supervision throughout the claim lifecycle
• Investigate and assemble facts, determine policy coverage, evaluate loss amounts, and analyze legal liability
• Handle multi-line property and casualty claims in an assigned territory, emphasizing property claims
• Study insurance policies, endorsements, and forms to become familiar with insurance coverage
• Work toward claim resolution and attend arbitrations, mediations, depositions, or trials as necessary
• Ensure claims payments are issued accurately and promptly
• Conduct investigations by phone, mail, and on-site visits
• Provide service to agents, insureds, and other parties to resolve claims accurately and timely

Field Claims Representative

• 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

Claims Representative

• Evaluate the appropriateness of beneficiaries’ admission to nursing facilities
• Evaluate the medical necessity of surgical and medical prior approval requests, including transplants, out-of-state evaluations, and surgeries
• Verify documentation supporting medical necessity of prior approval requests for long-term care facility admissions
• Evaluate the accuracy and timeliness of documentation submitted for surgeries and medical care prior approval requests
• Complete at least 30 prior approval reviews daily
• Achieve greater than 95% accuracy on quality assurance reviews
• Complete reviews within 24–72 hours to meet service-level agreements
• Update the system with prior approval decisions within 7 business days
• Contribute to process improvements

Claims Specialist jobs in North Carolina