CareFirst– Full Service Representative I


Job Title: Representative, Full Service I

Location: UCP/DC

Career Band:   II

Job ID #: 8882

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

1. Uses knowledge of products and the contractual provisions that govern administration to provide client education; interprets contract language to clients for the purpose of providing benefit utilization and limitations; determines need for managed care initiatives; and administers all types of service to a policyholder through face-to-face interactions, telephone communication, or written correspondence and claims adjudication.  Documents all client interactions according to established procedures.

2. Uses product knowledge to recommend products to clients appropriate with client needs which may result in the sale of complimentary products, an upgrade from current products, and/or sale of replacement products.

3. To effectively interact with clients, the incumbent applies an expert ability to analyze client need by current product mix, systems, managed care, risk assessment, and revenue impact along with expert communication and interpersonal techniques.

4. Executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, conversion in coverage, PCP changes, and transfers from other BCBSMD Plans.  Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account.

5. Administers all phases of client account management and the management of care dollars through the identification of pre-existing conditions, referrals, authorizations, knowledge of policies and riders, identification of other insurance and coordination of benefits, recovery of payment which is the legal responsibility of another insurance company, identification of benefit exclusions, identification of falsified application information, determination of the need or opportunity for case management, identification of fraudulent billing practices, terminal liability, and other party liability.

6. Accesses information from BCBSMD automated systems, by telephone and written inquiry with clients, providers, brokers, other Blues plans, and other insurance companies.  Responds to client, provider, broker, or other Blues plans inquiries (written, by phone, or in person) about benefits or disputes about adjudication decisions, assures accuracy of the decision, and educates the client on the methods applied.

7. To administer service, the incumbent must utilize a range of automated systems including, but not limited to the following:  EAB, CBS, Suspense, CIA, BCIQ, BIDS, BCXF, GMRI, PV40, PVOO, MPPC, CARE, NASCO, ITS, and MBO1. The incumbent must have excellent PC skills to utilize software such as Microsoft Word and Excel.

8. Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.

9. Processes all types of adjustments, and demonstrates the ability to resolve the most complex service and claims issues.  The incumbent is considered one of the most highly skilled, most valuable employees within the Division due to their blend of business, technical, flexibility, and customer relations expertise.


Required:  Position requires performance for 5 + years in customer service and claims at a meets standards level or above.  Demonstrates consistency in their ability to apply effective analytical, statistical, listening, oral and written communication skills.  Must also possess excellent interpersonal skills.

The incumbent has achieved the highest level of expertise in claims adjudication, inventory management, problem solving, and implementation of improved methods of manual or automated systems while managing routine tasks.

The incumbent must demonstrate Customer Contact excellence by achieving a minimum of three consecutive meets standards or above annual performance ratings prior to promotion and proven expertise in both in-person, and written customer communication.

Tangible demonstration in mastering independent judgment and exception-based decision-making when administering policy benefits, resolving client problems, and evaluation risk in complex business situations is required.

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:  BlueCard 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:  August 17, 2016

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


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