Qureos Mentor

CareFirst BlueCross BlueShield

<div>Resp &amp; Qualifications
PURPOSE:
 
Under minimal supervision, the Claims Recovery Specialist II review and audits medical and/or dental claims to recover payments. Specialist will assist to maximize recovery amounts due to refund of payments made in error to members and/or providers, retro terms and/or focused provider audits. Specialist will provide day-to-day management of active overpayment recoveries. This position will work closely with the claims, service, finance, and vendor auditing departments to complete claims adjustments. 
 
ESSENTIAL FUNCTIONS:<ul><li>
Under supervision, reviews, audits, and/or initiates recovery efforts for medical, and/or dental claims to recover overpayments, ensuring all parts of the process are documented properly.</li><li>
Contacts carriers, members and/or providers, via phone, email, and correspondence, to recover and settle overpaid and/or unpaid claims. Responds to carrier, customer and/or provider service inquiries regarding outstanding claims and/or overpayment balances. Proactively identifies needs and responds appropriately through investigating, problem solving, engagement of other internal or external resources, and providing high level service. Adjusts claims to reflect cash returned by members and/or providers to reduce and accurately reconcile customer accounts.</li><li>
Distributes written correspondence to policy holders to recoup overpaid claims, negotiate repayment agreements when necessary, and ultimately reduce the company's care line. Performs vendor education and training to educate vendors on claims retrieval systems and procedures, general vendor updates.</li><li>
Participate in all internal/external meetings relating to Audit and Recoupment. Improves claims audit and recoupment job knowledge by attending training sessions. Participates with department management in revising Audit and Recoupment SOPs.</li></ul>
QUALIFICATIONS: 
 
Education Level: High School Diploma or GED. 
 
Experience: 5 years claims processing. 
 
Preferred Qualifications:<ul><li>
1 year adjustment processing
</li></ul>Knowledge, Skills and Abilities (KSAs)<ul><li>
Mathematical ability/aptitude.</li><li>
Communication skills.</li><li>
Ability to deal with both internal and external clients.</li><li>
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.</li></ul>
Salary Range: $42,624 - $78,144
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Equal Employment Opportunity
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.
Federal Disc/Physical Demand
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.
PHYSICAL DEMANDS:
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.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship</div>

Claims Recovery Specialist II (Remote)

<div>Resp &amp; Qualifications
PURPOSE:
 
The Clinical Navigator (RN) conducts concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in utilization management, the Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care. The role will function as a liaison working telephonically with the hospital care team including case managers, social workers and discharge planners to ensure CareFirst members/enrollees receive the appropriate level of care and partner to address any potential barriers to discharge. The candidate may be required to come to the CareFirst office location periodically for meetings, training or other business-related activities. The candidate's primary residence must be within the greater Baltimore metropolitan area. Bilingual-fluent in Spanish a big plus! 
 
ESSENTIAL FUNCTIONS:<ul><li>
Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address member's medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.</li><li>
Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination.</li><li>
Makes referrals to other care management programs as appropriate for chronic, long-term care coordination.</li><li>
Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience.</li></ul>
QUALIFICATIONS: 
 
Education Level: Bachelor's Degree in Registered Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Upon Hire Required:
<ul><li>RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or
</li><li>Washington, DC
</li></ul>Experience: 5 years clinically related experience working in an acute care setting, and/or Utilization Review. 
 
Preferred Qualifications:<ul><li>
Knowledge and experience with MCG</li><li>
Experience working with Commercial and employee group member and Medicare/Medicaid enrollees and benefits contracts</li><li>
CCM certification</li><li>
MCG certification
</li></ul>Knowledge, Skills and Abilities (KSAs)
<ul><li>Strong interpersonal skills and the ability to engage in a member facing environment (telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs.</li><li>
Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.</li><li>
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point.</li><li>
Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.</li><li>
Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations.</li><li>
Knowledge of available community resources and programs.</li><li>
Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).</li><li>
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
</li></ul>Salary Range: $72,360 - $143,715
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Equal Employment Opportunity
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.
Federal Disc/Physical Demand
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.
PHYSICAL DEMANDS:
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.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-SS1</div>

Clinical Navigator (Remote)

<div>Resp &amp; Qualifications
PURPOSE:
 
The Political Action Committee (&quot;PAC&quot;) Manager focuses on the compliance and regulatory requirements for the organization's Political Action Committee and for federal, state and local lobbying disclosures. This role is responsible for day-to-day activities of the PAC including grassroots network maintenance, contribution disbursement, federal and state reporting, budgeting, and PAC Board governance. The PAC Manager works with the Government Affairs team to develop and implement internal processes related to PAC regulatory compliance.
 
 
ESSENTIAL FUNCTIONS:<ul><li>
Develops and executes political action strategies in conjunction with management. Responsible for all aspects of PAC management including meeting scheduling, grassroots network maintenance, contribution disbursement, federal and state reporting, budgeting, and PAC Board governance.</li><li>
Work with the Government Affairs team to develop and implement internal processes related to PAC regulatory compliance. Create and preserve documents and records related to PAC administration. Coordinate the completion of Federal, state, and local lobbying disclosure documents, registration and reporting.
</li><li>Lead intake, processing, and distribution of all federal and state disbursements. Coordinate with compliance to ensure Federal Election Commission reports and State election commission reports are filed accurately and in a timely manner. Manage the PAC database and work with outside consultants to maintain data and follow best practices.</li><li>
Coordinate with Finance on payroll and payments processing. Assist with PAC budget development and support throughout the election cycle. Assist with preparation of materials for PAC board meetings and development of meeting minutes and other reports.</li><li>
Prepares presentations, reports, statistical charts, communications and briefings.</li></ul> 
SUPERVISORY RESPONSIBILITY: 
This position has no direct reports, however, may informally lead teams in a matrix environment. 
QUALIFICATIONS: 
Education Level: Bachelor's Degree in Political Science, Business, Communications, Marketing, Journalism, English, or related field required OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. 
 
Experience: 8 years relevant political, project management strategic communications, and/or compliance experience. This could include experience working in congressional office, lobbying or public relations firm, political campaigns or a trade organization. 
 
Preferred Qualifications: 
Experience in a healthcare organization. 
 
Knowledge, Skills and Abilities (KSAs)<ul><li>
Excellent communication skills both written and verbal.</li><li>
Ability to develop and implement strategies that advocate CareFirst positions on legislation, regulation or governmental trends.</li>
Knowledge of state and federal government affairs and politics. 
<li>
</li></ul> 
 
Salary Range: $87,408 - $173,602 
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Equal Employment Opportunity
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.
Federal Disc/Physical Demand
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.
Physical Demands:
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.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship.
#LI-LJ1</div>

PAC Manager (Hybrid)

Join CareFirst BlueCross BlueShield and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

CareFirst BlueCross BlueShield

About Company

Claims Recovery Specialist II (Remote)

Clinical Navigator (Remote)

PAC Manager (Hybrid)