OPL Specialist I (Remote)

CareFirst • Reston, VA • 6h ago

Resp & Qualifications

PURPOSE:

Under direct Supervision, responsible for collecting payments from liable parties and insurance companies through the administration of coordination of benefits, Subrogation or Workers' Compensation. The associate will investigate claims and assert liens to ensure the company's right of recovery under subrogation provisions and to recover payments subject to Workers' Compensation exclusions in the member's contract.

ESSENTIAL FUNCTIONS:

Responds to provider, health plan, and member phone calls and correspondence.

Investigates billing and payment issues including but not limited to denied claims for members with other primary insurance sources. Processes refunds and retraction requests.

Interprets information pulled from the Workers Compensation Commission files for disputed workers compensation cases, and or contracts employers and compensation carriers as necessary to obtain case details.

Files claims, sends letters and/or liens for direct payment for services rendered and assists the claims department to avoid and/or recoup payments made that are not considered other party liability.

Reviews active cases regularly to identify additional paid care related to subrogation and compensable work injuries. Researches the status of employer-disputed cases to include checking Workers Compensation Commission files when necessary.

Records and logs all recoveries in the appropriate system related to the case. Monitors and records the progress of third party suits and periodically updates case lien amounts.

Recognizes case review opportunities for improvement and collaborates with other staff to ensure that Subrogation and Workers Compensation functions are effectively administered throughout the organization.

Negotiate with attorneys on the settlement of Subrogation liens and can exercise independent judgment and discretion within those negotiations within the settlement guidelines.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 3 years experience in Subrogation, Workers Compensation or Medicare Second Payer (MSP) with a general knowledge of third party reimbursement.

Knowledge, Skills and Abilities (KSAs)

Excellent interpersonal and communication (written and oral) skills for liaison work with co-workers, internal and external clients.

Position requires excellent proofreading, organized work habits which include attention to detail, ability to prioritize work and handle multiple tasks in a fast-pace setting.

Must have good analytical skill with problem-solving skills with ability to apply sound judgment to the decision-making process.

Must be customer-focused and goal-oriented.

Salary Range: $34,848 - $63,888

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-ZW1

REQNUMBER: 22066

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