CareFirst– Customer Service Representative II


Location: FAIRFAX VIRGINIA                                                         Career Band:  BAND II


Job ID #: 8147


PRINCIPAL ACCOUNTABILITIES: Under the direction of either a Manager or a Supervisor, the incumbent’s essential duties and responsibilities include, but are not limited to, the following: •Uses knowledge of products and the contractual provisions that govern administration to provide customer service and education, to interpret contractual language to the customer for the purpose of providing benefit utilization and limitations, to determine the need for managed care initiatives, and to administer all types of services to customers within the business segment through telephonic inquiries, written and/or electronic inquiries and claims adjustments •Examines adjudicated claims to identify key elements and processing requirements based on diagnosis, procedure, provider, medical policy, contracts and policy procedures.  Researches, investigates and initiates resolution of pends by the processing system.  Calculates and verifies deductibles, maximums, co-payments and coinsurance for resolving inquiries, facilitating adjustments, initiating extra contractual and reporting of any systems processing errors, overpayments and underpayments.  Develops and applies the ability to analyze customer contracts and needs involving current product mix, risk assessment, and revenue impact.  Develops service techniques and technical competence for the purpose of maximizing customer retention, satisfaction, and potential financial savings.  •Effectively utilizes NASCO and/or CARE and/or FLEXX systems, products, contract and medical policy knowledge and processing techniques to resolve client inquiries.  Demonstrates the flexibility to process and service various types of products within each line of business according to the established quality, productivity and performance metrics. Learns and retains the ability to access information and effectively administer services using the company’s automated systems.

  • Learns information required to effectively provide service to clients as it relates to inquires concerning pre-existing condition, knowledge of policies and riders, identification of other insurance and coordination of benefits, benefit exclusions, administration of direct pay, credit card payment, debit accounting and other enrollment and billing transactions. Appropriately documents all client interactions according to established departmental procedures.  QUALIFICATION REQUIREMENTS: Required: High School diploma or equivalent.  Minimum of 0-2 years of previous customer service experience in a service or claims environment.     Abilities and Skills: Use of automated systems, PC or CRT proficiency, excellent oral and written communication skills, time management and organizational management skills.  Strong   analytical ability and problem-solving skills necessary to work effectively in a high volume, fast paced work environment.  Must have experience in performing job functions that are detailed in nature, requiring strong follow-up skills, active listening and decision making skills based on quality and service expectations. Preferred:  1-2 years of college in Business or other related field.  Healthcare and/or Insurance industry experience preferred. Call Center experience preferred.   Bilingual in Spanish, etc. is a bonus.

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted

Department:  Call Center

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Actual salary will be based on relevant job experience and work history.


Please apply before: January 13, 2016

Must be eligible to work in the U.S. without Sponsorship


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