Triage Specialist

Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

Location: Hybrid

Compensation: $25.33 - $34.23

Jump into the new world of health insurance:

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength:

We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Why this job matters:

Review all incoming requests to determine if the request is a grievance/complaint, appeal or if it needs to be redirected to another department. Responsible for reviewing internal systems to determine case type and liability and creating a case within the system of record by entering required data. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Service requirements. Maintain all appeals documentation according to external agency requirements. Serve as back-up to department quality assurance functions such as quality control of cases and letters.

What you will do:

• Identify the appropriate company received date, case type, line of business, priority, liability, root cause and authorized appointment of representation for each case opened within the system of record. Open cases within 48 hours of company received date.
• Review and associate members, provider and claims as well as attach documents to cases within the system of record.
• Respond to internal and external inquiries.
• Redirect non-GAU request to appropriate departments.
• Identify potential quality of care issues or fraud waste abuse concerns and escalate as appropriate.
• Maintain a thorough and comprehensive understanding of CMS, and NCQA regulations as related to business areas to ensure cases are opened appropriately.
• Participate in department projects and initiatives.
• Perform other duties as assigned.
  
  

What you need to succeed:

• High school degree
• Four or more years of experience in a health insurance environment
• 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
  
  

Extras

• Associate’s or Bachelor’s degree in related field, or an equivalent combination of education and experience
• Proficiency with Microsoft Suite of products, i.e., Word, Excel, PPT, etc.
• Prior health insurance industry experience (i.e. Customer service, Claims, Systems)
  
  

Location:

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
  
  

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.

The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit https://www.eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.

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