Job description

Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Schedule: In Office, Hybrid or Remote
Compensation: $23.37 - $30.38 per hour

Why this job matters:
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.

What you will do:

• 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.

What you need to succeed:

• Two to four years experience in a managed care environment
• Demonstrated experience in timely processing of complaints and appeals

Not sure if you meet the qualifications for the job? Reach out to your HRBP to discuss your interest and experience!

The extras:

• Proficiency with Microsoft Suite of products; i.e., Word, Excel, PPT, etc
• Prior health insurance industry experience (Customer service, Claims, Systems)
• 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

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Florida, Georgia, Louisiana, North Carolina, Oklahoma, South Carolina, Texas, Rhode Island, Massachusetts, Connecticut and Virginia.

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
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 https://www.eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.

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