As a Claims Adjuster I at CareFirst BlueCross BlueShield, you will play a pivotal role in the insurance claims process, ensuring accurate and timely resolution of member claims. This position is crucial for maintaining customer satisfaction, controlling costs, and supporting the company's mission to provide accessible healthcare coverage across the Mid-Atlantic region. Your work directly impacts the financial health of the organization and the trust of our policyholders, contributing to our reputation as a leader in health insurance services. In your daily responsibilities, you will review incoming claims for completeness and accuracy, conducting thorough investigations by gathering medical records, policy details, and statements from providers and members. Weekly, you will analyze claim documentation using industry-standard guidelines to determine coverage eligibility, calculating payouts based on contractual terms and state regulations. You will negotiate settlements with healthcare providers, document all decisions in our claims management system, and collaborate with underwriting teams, legal departments, and medical reviewers to resolve complex cases. Monthly, you will prepare reports on claim trends, participate in audits to ensure compliance, and handle escalations from dissatisfied members, aiming to meet key performance metrics such as turnaround time under 30 days and approval accuracy above 95%. This role involves no direct management but requires strong coordination with cross-functional teams to deliver high-quality outcomes. To succeed in this role, candidates must possess a high school diploma or equivalent, with a bachelor's degree in business, finance, or a related field strongly preferred. At least one year of experience in insurance claims processing or customer service within the healthcare sector is required, along with familiarity with CPT, ICD-10 coding, and HIPAA regulations. Proficiency in claims software such as FACETS or similar platforms, Microsoft Office Suite, and strong numerical aptitude for financial analysis are essential. Industry knowledge of health insurance policies, including BlueCross BlueShield plans, is necessary, and holding certifications like Associate in Claims (AIC) or similar is highly advantageous. The ideal candidate excels in analytical thinking, attention to detail, and problem-solving to navigate intricate claim scenarios. Strong communication skills, both written and verbal, are vital for interacting with diverse stakeholders, while organizational abilities ensure efficient multitasking in a fast-paced environment. You should demonstrate empathy in handling sensitive member situations, adaptability to evolving regulations, and a commitment to ethical decision-making, paired with technical proficiency in data entry systems and report generation tools. CareFirst BlueCross BlueShield, headquartered in Baltimore, MD, is a not-for-profit health insurer dedicated to improving health and wellness for over 3 million members. Our mission emphasizes innovative care delivery and community well-being, guided by values of integrity, collaboration, and member-centric service. The claims team operates in a supportive, remote-friendly environment with diverse professionals fostering knowledge sharing and continuous improvement, making us a unique place to grow in the healthcare insurance industry. We offer competitive compensation, though salary details are not specified at this time, commensurate with experience. Comprehensive benefits include medical, dental, and vision coverage, a robust 401(k) retirement plan with company match, generous paid time off starting at 20 days annually, and remote work flexibility with optional hybrid opportunities. Additional perks encompass tuition reimbursement, wellness programs, employee assistance services, and performance-based bonuses to reward excellence. Advance your career with clear paths to senior adjuster roles, claims supervision, or specialized units like fraud investigation. We invest in your growth through ongoing training, certification support, and mentorship programs. Apply today via our careers portal to join our impactful team and shape the future of health insurance.