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CareFirst BlueCross BlueShield Claims III- Stop Loss Adjuster in Baltimore, Maryland

Resp & Qualifications


Under the direction of the Supervisor, the incumbent’s accountabilities include, but are not limited to, the following:

  1. Research and analyze technical issues to ensure that methodologies are appropriate and consistent. Ensure all processing/adjusting/recovery requirements met to generate appropriate end-result. Complete the entry of new data and process/adjust transaction to the point of completion in a timely and accurate manner. Assist the adjustment unit by adjudicating complex claims and adjustments, and adjustments related to the most corporately visible and time sensitive situations such.

  2. Analyze and resolve claim edits and deferrals daily. Complete the processing of these adjustment transactions in a timely and accurate manner to prevent a negative impact on corporate time lapse. Serve as the primary resource for assisting the Supervisor with training new adjusters and developing Adjusters I’s and II’s. Identify problems or trends related to adjustments performed. Initiate problem reports for corrective action. Assist the Supervisor for testing system fixes and other system projects.

  3. Maintains reports and updates cases on daily basis. Gathers own productivity data daily and refers information to Supervisor. Monitors emails, voice mails, and various updates to ensure proper procedures are followed. In the absence of the Supervisor, perform as team leader assuring the unit’s goals are met.

  4. Perform other duties as assigned, including providing phone support if needed. Identify problems or trends related to adjustments performed.


Required: The incumbent must possess a high school diploma/ GED and at least 3 years of proven expertise processing claims and overrides on the appropriate system. Must have a thorough understanding of managed care, CDH, CPT IV coding, ICD-9 coding, CareFirst benefits coverage, CABAs (Comprehensive Account Benefit Analysis – this marketing document is used by systems to program the benefits for a group), HBP (Health Benefits Policy), policies and procedures for membership processes, and various computer systems.

Abilities/Skills: In addition to the duties of the Adjuster I and II, consisting of:

Strong analytical and problem solving skills with emphasis on highly detailed work, comprehensive mathematical, PC, effective communication (written/oral), time management and organizational skills, ability to work independently and as part of a team, with a high degree of demonstrated dependability. Flexible, detail oriented, self-motivated with fast learning capacity and stress management skills.

The candidate should also possess exceptional research and analytical skills, and oral and written communication skills; an advanced knowledge of Medicare/COB, and an intermediate knowledge of all the platforms by which we receive/conduct adjustment requests, including but not limited to Cash Refunds, CBAS, IACS, PIP recovery guidelines. Basic PC knowledge; exemplary quality work record with consistent quality achievement; exemplary attendance record is required. In addition, the candidate should meet expectations and/or job requirement with little to no Supervisor intervention.

Preferred: Stop Loss Knowledge and Claim Experience. Spreadsheet knowledge and advanced Excel skills knowledge; using current systems; leadership skills.

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.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 5.28.21

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.


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