Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Plan to Plan Service Specialist III will be responsible for serving as a single point of contact in responding to all Plan to Plan claims inquiries and resolving related issues. Plan to Plan Service Specialists may support Home (representing members) which would require strong knowledge of member benefits, medical policy and authorization as well as JAA/TPA relations; Host (representing providers) which would require strong knowledge of pricing, provider contracting/coding and medical pricing policy; or both of these lines of business.
How you will make an impact:
Supports inquiries from other BCBS Plans that were unable to be resolved through normal channels.
Works with internal business partners (sales, member experience, claims, medical review, appeals, etc.) and external contacts within the other Blues plans to address all inter-Plan claims issues.
Performs all aspects of customer service and manages adjustments, ITS processing, keying, rate negotiation, grievance and appeals, escalations, etc., in providing a seamless Blue customer experience.
Understands all lines of business, including all subsets within the products, and all of the related systems.
Resolves Plan to Plan emails and Blue 2 General inquiries.
Requests and routes medical records to medical review units.
Keys, processes and adjusts claims for all lines of business.
Fully proficient in all key areas; performs many complex functions and provides leadership to other Specialists.
Actively seeks, evaluates and understands information needed to make effective decisions.
Works independently.
May represent the unit as a subject matter expert.
Handles special projects as assigned.
Minimum Requirements
Requires a HS diploma or equivalent and a minimum of 5 years of experience in an automated customer service or claims environment.
2 years of inter-plan experience; or any combination of education and experience which would provide an equivalent background.
