FEP Service Specialist

Position Summary:

The FEP Service Specialist is responsible for investigating and resolving complex written inquiries and appeals to ensure timely and accurate claims adjudication. This role collaborates across the FEP Business Unit as well as other business partners to identify opportunities for process improvement and provider education, directly contributing to our commitment to service excellence. This role is perfect for a detail-oriented problem-solver who excels at critical thinking and thrives in a collaborative, fast-paced environment.

This position is eligible for the following persona(s): eWorker, mobile, resident.

Core Responsibilities:

• Inquiry and Appeals Resolution:Research, analyze, and resolve written provider inquiries and claims appeals with a high degree of accuracy, meeting all timeliness goals
• Claims Adjudication:Navigate a dual-system environment (FEP National, NASCO) to accurately interpret contracts, adjudicate claims, and manage pricing arrangements
• Clinical Case Research:Facilitate research for inquiries requiring medical review by documenting information in the Medical Management System (MHK) and coordinating with RN reviewers
• Risk & Compliance:Proactively identify and mitigate potential risks to ensure Plan compliance and performance by adhering to all internal policies (e.g., BCBSMA payment policy, FAM II, FEP medical policy)

Collaboration and Process Improvement:

• Service Excellence:Provide exceptional service to both internal and external customers, aiming for first-contact resolution.
• Trend Analysis:Identify trends, errors, and opportunities for process improvements that increase efficiency and satisfaction for members, providers, and accounts.
• Team Contribution:Actively contribute to team efforts to meet and exceed service, production, and quality standards. Participate in cross-functional teams to help achieve FEP Plan Incentive Program (PIP) goals.
• Caseload Management:Skillfully prioritize and manage your caseload to meet and exceed production goals for inventory levels.

Qualifications:

• Experience:2+ years of successful experience in a customer service or healthcare operations environment. Experience with FEP is preferred.
• Technical Skills:Strong computer skills with proficient knowledge of NASCO (including claims adjudication), Medical Management System (MHK), and other web-based business applications

Key Competencies:

• Excellent organizational, critical thinking, and problem-solving abilities.
• Strong verbal and written communication skills.
• Demonstrated ability to work independently while also being a flexible, self-motivated team player.
• Adept at giving and receiving feedback in a constructive and positive manner.

Education:

• High school diploma or equivalent is required. A college degree or comparable work experience is preferred.

#LI-HYBRID

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.