Member Service Representative II (Hybrid)

The Rep, Member Service II is responsible for complex benefits, claims, and general inquiries. They have broader knowledge of the following: systems, benefits, contracts/products, functions of other departments in the company, standard operating procedures, claims status, enrollment/billing and follow-up to a customer inquiry. ESSENTIAL FUNCTIONS:

Answers complex member inquiries by clarifying desired information; researching, locating, and providing information. Resolves complex member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems.

Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures. Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.

Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other BCBS 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, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.

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

Assist with training of new hires.

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.

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.

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.

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

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