Job Description
We’re hiring an Operations Specialist to join the Quality, Health Engagement, and Risk Adjustment Team! This individual will provide cross-functional and cross-team support for operational and/or healthcare functions supporting members in the Medicare Advantage and ACA populations and other LOBs as assigned, to ensure Quality and Risk Adjustment care gaps are addressed and closed by guiding the member to a PCP, advising of available benefits in support of the member’s health, and providing assistance with navigating these benefits if needed.What You’ll Do
Perform at the expected level of service to enhance customer interaction and experience.
Provide regular communication to leadership and other team members on the results of member and/or provider engagements including the potential to participate in regular meetings with key stakeholders and members of upper management.
Perform outreach based on assignments received through various methods, including outbound calls to various providers, members, vendors, or other outside contacts to increase health behavior participation and drive positive health outcomes for our members.
Make direct calls to members using effective engagement strategies to respectfully encourage members to utilize available benefits in support of member health behavior participation.
Maintain member confidentiality per HIPAA compliance guidelines.
Coach, educate and guide members in health program participation and preventive care tactics.
May support other team members through referrals, mailbox management, work assignment and relevant documentation.
Service as the subject matter expert around work process, procedures, products, and policies and provide support, first level escalation, and research support as needed.
May assist in the review and updating of existing and creation of new processes & procedures.
Provide cross functional support and departmental expertise to varied internal stakeholders.
Responsible for maintaining reports, tracking and/or data analysis as assigned or as needed.
Performs other tasks as assigned by leadership.
What You Bring
High school diploma or GED
3+ years of experience in related field.
Bonus Points (Preferred qualifications)
Experience working with operational healthcare systems is highly preferred.
Highly Preferred Systems Experience:
Facets – Experience navigating member records, eligibility, benefits, and healthcare-related information.
Genesys – Proficiency in call management, queue monitoring, outbound and inbound call activities, wrap-up documentation, and performance metrics.
Salesforce – Experience documenting member interactions, managing cases, tracking outreach activities, and maintaining accurate records.
Blue Connect – Ability to navigate member-facing healthcare tools and resources to support member inquiries and engagement activities.
Microsoft Excel – Strong working knowledge of Excel, including data entry, filtering, sorting, reporting, spreadsheets, and basic data analysis.
What You’ll Get
The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
Learn more
Where You’ll Work
Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused.
In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.
Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
$41,600.00 - $66,561.00Skills
Case Management, Customer Service, Documentations, Enrollment Management, Insurance Eligibility Verification, Medicaid Documentation, Operations Support, People Management, Process Improvements, Workflow Management
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on . If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: .
Originally posted on Himalayas
