Blue Cross Blue Shield of Rhode Island Triage Specialist - Commerical in Providence, Rhode Island

Triage Specialist - Commerical

| Job ID 727 | Posted: 12/07/2018

Job DescriptionReview all incoming requests to determine if the request is a grievance/complaint or appeal or if it needs to be redirected to another department. Responsible for reviewing internal systems to determine case type and liability and for 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 Services 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.


  • 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 associate member and provider 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.


Minimum Education and Experience:

  • High school diploma.

  • Four or more years of experience in a health insurance environment.

Preferred Education, Additional Qualifications, and Experience:

  • 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, PowerPoint, etc.

  • Health insurance industry experience (i.e., customer service, claims, systems).

Required Knowledge, Skills, and/or Abilities:

  • Knowledge of health insurance laws and regulations.

  • Working knowledge of Microsoft Office, including Excel and Word.

  • General computer proficiency.

  • Written and verbal communication skills.

  • Good organizational skills.

  • Time management skills.

  • Detail-oriented.

  • Ability to research and organize data.

  • Ability to organize work efficiently to meet established time and quality standards.

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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, age, national origin or ancestry, disability, veteran status, sexual orientation, genetic information, sex, gender identity or expression, and any other personal attributes protected by federal, state, or local law. For more information about our commitment to diversity and inclusion, please see our Diversity Report

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BCBSRI is committed to working with and providing reasonable accommodation to individuals with disabilities. If, because of a disability, you need a reasonable accommodation for any part of our application process, please contact us at (401) 459-1050 for assistance.

During the application process, please allow a minimum of five business days before you contact our office to inquire about the status of your application. If you have any questions regarding your application or during the process, please contact Human Resources by phone at (401) 459-1050 or by email

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