CareFirst–Service Claims Specialist


Job Title: Specialist, Service/Claims

Location: UCP/DC

Career Band:   II

Job ID #: 8717

This position requires a total knowledge of claims service work methods as well as other departments’ processing methods and serves as a subject matter expert in BlueCard Home/Host, Flexlink and other lines of business. In order to be effective, the incumbent requires an ability to work well with people, to communicate well in oral and written skills and to possess leadership and motivational skills. The incumbent must be able to support and mentor new associates who will need to be integrated into the customer service system.

The Claims Service Specialist represents a lead role in the operations of the claims department by assisting the supervisor in maintaining inventory volumes, supporting the supervisor in handling of associates’ questions, providing on-the-job training, and assisting in identifying, communicating, and resolving issues for management and staff. This position follows normal reporting and monitoring guidelines, but has the freedom to perform daily activities and special projects with independence while being accountable for meeting pre-established goals.

Under the direction of the Supervisor, the essential duties and responsibilities include, but are not limited to, the following:

Assist Claims Associates with inquiries and questions that notably improve performance in their work in an effort to help meet goals. Identifies problems with work flow, procedures or benefits with resolution or brings to management attention. Coaches, counsels, and educates Processors on policy changes, system updates, learning tools, and other job requirements in order to provide a consistent base for new employees. Oversees the progress of employees after they have completed the formal training program assuring that they perform to optimum satisfaction. Provides associates with effective direction and feedback to aid in the completion of their assigned duties and responsibilities in a timely manner. Supports cross-training to occur within the division as part of this development.

Investigates and resolves sensitive, complex, and/or high priority claims inquiries. Maintains an in-depth knowledge of all lines of business, claims procedures and regulations related to the health insurance industry. Serves as liaison with other departments within the company to negotiate the resolution of claims inquiries. Investigates, analyzes, and resolves complex claims issues. Effectively responds to internal customers in writing including explanations and a summary of actions to be taken. Advises the management of inquiry related activities that require a course of action to enhance customer/provider satisfaction.

Performs selected supervisor responsibilities in the absence of management. Manages routine supervisory tasks and exercises good judgment in making decisions in the absence of management. Supports the supervisors in the daily operation of units and assuring the timely flow of work. Effectively represent the claims department by participating in assigned committees, quality improvement teams, and projects. Supports timely and accurate implementation of quality improvement projects by serving as a project team leader or team member. Provides feedback and communication to claims associates, management and staff. Performs additional job related duties or special projects as requested by the Supervisor.

Maintains technical quality in responding to customers by demonstrating pre-determined performance in areas such as accuracy of response, completeness and accuracy of tracking, completeness and accuracy of work orders including appropriate follow-up.  Identifies, researches, and corrects problems. Interacts with CSR and other specialists within the department to identify global, procedural, or patterns of problems and initiates resolution to these problems by recommending departmental procedure/process changes to the supervisor. Communicates with others to prevent future problems.


High School Diploma or equivalent.  Minimum of 3-5 years of prior claims or service experience and of those 3-5 years, at least 1+ year for a health insurance company.

Strong Systems experience to include: NASCO experience and Flexlink processing.
Thorough understanding of BCBS claims and service systems, and reports is necessary.
Detailed knowledge of benefit packages, membership and claims systems, administrative and internal procedures is essential.

– Analytical, training, problem-solving, and decision making skills
– Mathematical aptitude, organizational and time management skills
– Detail-oriented
– Proven leadership, coaching, mentoring and motivational skills
– Demonstrated excellence in both oral and written interpersonal skills to include the ability to compose effective    business letters
– Ability to organize and deliver presentations
– Strong PC skills with a proficiency in using Microsoft Word, Excel, Access, and PowerPoint
– Ability to work effectively under the pressure of deadlines
– Strong multi-tasking ability

The physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.

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 of up to 25 pounds are occasionally lifted.

Department:  Blue Card Claims Support    


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.

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.

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

Please visit our website to apply:

Please apply before:  July 5, 2016

Actual salary will be based on relevant job experience and work h


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