Case Spec - GAU

This a Full Remote job, the offer is available from: United States Pay Range $52,800.00 - $65,800.00 Please email [email protected] if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join Others Who Value a Workplace For All. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. What You’ll Do • Investigate and resolve member and provider complaints, benefits appeals, and administrative appeals for all company products. Maintain documentation of cases. • Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication. • Assist members gain a better understanding of the plan through education. • Identify potential quality of care issues; escalate as appropriate. • Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary. • Participate in departmental audits in preparation of regulatory site visits. • Participate in department initiatives and projects. • Perform other duties as assigned. What You Need To Succeed • High school degree • Two to four years experience in a managed care environment • Proficiency with Microsoft Suite of products; i.e., Word, Excel, PPT, Teams, Sharepoint; Office etc • Systems/Software – Salesforce (system of record for appeals and grievances), Outlook, , Prime Rx, FACETS, MacessPrior health insurance industry experience (Customer service, Claims, Systems) Required Knowledge, Skills, And/or Abilities • Knowledge of health insurance laws and regulations • Working knowledge of Microsoft Office including Excel, and Word • General computer proficiency • Written and verbal communications skills • Good organization skills • Time management skills • Detail oriented • Ability to research and organize data • Ability to organize work efficiently to meet established time and quality standards Location: Role BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: • In-office: onsite 5 days per week • Hybrid: onsite 2-4 days per week • Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster. This offer from "Blue Cross & Blue Shield of Rhode Island" has been enriched by Jobgether.com and got a 72% flex score. 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