Operations Specialist Blue Cross Blue Shield of North Carolina 627 reviews - Durham, NC The Operations Specialist is responsible for the resolution of inquiries and/or activities which may include claims, plan policies, products, rates, membership, enrollment, underwriting, direct sales and/or program engagement. The Operations Specialist may also provide cross-functional support for operational functions, which may include one-on-one training, auditing, fulfillment, and/or root cause analysis. * Identify and document escalated, recurring or complex system and process problems. Interface with project teams to resolve these complex issues. * Serve as a subject matter expert for employees inquiries around work process, procedures, products, policies, etc. * Develop and maintain assigned reports (i.e. team level, inventory) on a daily, or as required basis. * Identify problems, gaps or inconsistencies in workflows, and/or processes; recommend updates, alternatives and/or solutions. * Act as a point of contact for internal and/or external audits and projects as necessary; assist in planning, scoping, testing, training and implementation. * May place outbound calls to various providers, customers or other outside contacts. * Monitor and evaluate operational processes and interactions for quality assurance purposes as requested. * May perform quality reviews of operational inquiries to determine the accuracy of information provided and ensure employees are functioning at the expected level of service to enhance customer interaction. Communicate the results of the reviews to improve individual and overall performance and make recommendations for coaching and training as necessary. * Handle special projects as necessary; create and report on project data analysis. Customer Service and Sales (in addition to above): * Act as the first level of escalation for more complex customer, provider, and/or group sales problems and/or complaints. * Identify quality trends related to inquiries received from internal/external customers and recommend updates to internal quality gaps. Work to reduce or eliminate the error. * Provide cross functional support between customer service and sales professionals and membership, underwriting and claims departments. * Provide coaching to Customer Service and Sales Professionals by assisting them with customer calls and inquiry research. * May work with case managers and be assigned advanced one-on-one personalized care for members. Claims (in addition to above): * Process a variety of customer transactions that may include suspended claims, inquiries, adjustments, and/or correspondence. * May determine benefit eligibility on suspended claims for specific products by utilizing medical records, certificate/benefit provisions, and clinical knowledge. * May act as a point of contact for NCQA and NCDOI compliance for Commercial Operations. Communicate compliance needs to management staff. Ensure that NCQA and NCDOI are provided with the appropriate documentation. * May serve as the first level of resolution for complex claims. Member Health Partnership Operations (Engagement, Fulfillment, Intake and UMC (in addition to above): * Make direct high volume outreach calls to targeted members utilizing effective engagement strategies and motivational interviewing techniques. Utilize soft sales techniques to respectfully encourage members to engage in Case Management services. * Coach, educate and guide members in case management and health program participation. * Identify trends based on forecasted information in order to achieve optimum Fulfillment accuracy, efficiency and customer satisfaction. * Act as the first level of escalation for more complex and urgent inquiries from providers or members. * May work with Medical Directors and clinical staff to respond to providers/members regarding utilization management and post decision inquiries. Membership Operations (in addition to above): * Act as point of escalation between Operations and Underwriting/Actuarial teams. * Provide cross functional support between membership and sales professionals and underwriting departments. * May work on project or process improvement initiatives impacting Group and/or Individual membership. * Provide coaching to Membership, Telephone Interview and/or Rating Specialists to assist with quality or work processes. * Direct contact for systems issues and related problem reporting.. * Key contact for QA and UAT testing. Assists in the coordination work to be tested on validation weekends. May also assist with validation on release weekends. * Assist in the review and update of SOPs for Membership and key business partners. * Handle more complex problems of eligibility and documentation with producers. May provide additional information to underwriting staff when submitting referrals for exception consideration. Hiring Requirements * High School Diploma or GED * 3 years in an operations area and 1 year experience in related functional area. Hiring Preferences * Ability to provide high quality customer service to both internal and external customers while working in a high-pressure environment * Effective oral and written communication skills * Detail oriented, flexible, dependable and able to prioritize work and manage time effectively * Ability to work in teams and independently * Exercises good judgment in decision making * Requires analytical and problem-solving skills and the ability to make timely decisions * Ability to present ideas professionally and represent business unit or department in various workgroups and as subject matter expert * Excellent interpersonal skills. 2 hours ago - save job - original job Apply On Company Site Other jobs you may like Operations Associate DICK'S Sporting Goods - Durham, NC Dick's Sporting Goods - 7 days ago Sales Operations Specialist - 18205535 CTG - Research Triangle Park, NC 12 days ago Electrical Journeyman - North Carolina Operat... 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