Operations Specialist

Job Description

Responsible for utilization letter development, collection of report data, resolution of inquiries and/or activities which may include knowledge of claims, plan policies, products, rates, membership, enrollment. 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.

What You'll Do

• Identify and document escalated, recurring or complex system, process and workflow problems; identify trends, recommend solutions/alternatives and work to resolve issues.  
• Serve as a subject matter expert for employees’ inquiries and internal/external audits/projects around work process, procedures, products, and policies and provide support, testing, coaching or first level escalation, and research support as needed. Provide cross functional support and departmental expertise to varied internal stakeholders.
• Responsible for departmental reporting, tracking and/or data analysis as needed.
• Perform quality reviews of 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.
• Process a variety of transactions that may include suspended claims, inquiries, adjustments, and/or correspondence.
• Determine benefit eligibility on suspended claims for specific products by utilizing medical records, certificate/benefit provisions, and clinical knowledge.
• ·Act as a point of contact for compliance and communicate compliance needs to management staff. 
• Make direct high volume outreach calls to targeted members utilizing effective engagement strategies and soft sales techniques to respectfully encourage members to engage in Case Management or Disease Management services. May place outbound calls to various providers, customers or other outside contacts.
• Coach, educate and guide members in case management and health program participation to increase enrollment and drive positive health outcomes for our members.
• May include coordinating relevant mailings of educational or other company materials to members.
• May assist the Utilization Management team with member and provider letter development.
• Adhere to NCQA timeliness for member letters and documentation requirements.
• May support clinical staff through referrals, mailbox management, work assignment and relevant documentation.
• May assist in the review and update of SOPs for Membership and key business partners.
• May handle more complex problems of eligibility and documentation with producers. May provide additional information to underwriting staff when submitting referrals for exception consideration.

What You'll Bring (Hiring Requirements)

• High school diploma or GED
• 3+ years of experience in related field

Salary Range

At Blue Cross NC, we take …