Case Specialist - GAU

Pay Range:

Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people. 

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self. 
It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. 

We’re dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

The GAU Case Specialist is responsible for investigating, managing, and resolving member and provider grievances, complaints, and appeals in accordance with organizational policies, regulatory requirements, and service-level agreements. This position performs detailed research, analyzes information from multiple sources, documents findings, prepares written determinations, and ensures all cases are processed accurately, timely, and in compliance with CMS, NCQA, state, and internal requirements.

What you will do:

• Manage a caseload of grievances, complaints, and appeals from receipt through final resolution.
• Review and analyze case documentation, claims information, benefit plans, policies, contracts, and supporting records.
• Conduct thorough investigations to determine the appropriate outcome for each case.
• Document all case activity, research, and determinations in designated systems.
• Ensure compliance with all regulatory and internal timeliness requirements.
• Monitor assigned inventory and proactively communicate potential barriers to timely completion.

Research and Analysis

• Research member, provider, and claim issues utilizing multiple systems and data sources.
• Collaborate with internal departments, clinical staff, business partners, and external vendors as needed to obtain information required for case resolution.
• Analyze contract language, medical policies, benefit plans, and regulatory guidance to support case determinations.
• Identify trends, process gaps, and opportunities for operational improvements.

Documentation and Regulatory Compliance

• Maintain complete, accurate, and audit-ready case documentation.
• Ensure all required fields, regulatory categories, and reporting elements are accurately completed.
• Adhere to CMS, NCQA, HIPAA, state regulatory, and organizational requirements.
• Support internal and external audit activities as requested.
• Follow established departmental workflows, policies, and procedures.

Communication and Correspondence

• Draft and generate acknowledgment and determination letters.
• Communicate professionally with members, providers, delegates, and internal stakeholders.
• Participate in meetings, huddles, training sessions, and calibration activities.
• Provide clear and concise explanations regarding case findings and determinations when appropriate.

Quality and Performance

• Meet established productivity, quality, and timeliness standards.
• Maintain satisfactory quality review scores and documentation accuracy.
• Demonstrate accountability for assigned work and performance goals.
• Participate in continuous improvement initiatives and process enhancement efforts.
• Assist with cross-training and departmental projects as assigned.

Success in this role is measured by

• Case timeliness and SLA compliance.
• Quality audit results.
• Documentation accuracy and completeness.
• Productivity and inventory management.
• Regulatory compliance.
• Collaboration and professional communication.

What you need to succeed:

• Strong analytical and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to interpret regulatory requirements, policies, and benefit plans.
• Strong organizational and time-management skills.
• Ability to manage multiple priorities in a deadline-driven environment.
• Attention to detail with a focus on accuracy and compliance.
• Proficiency using Microsoft Office applications and case management systems.
• Ability to work independently and collaboratively within a team environment.
• Two or more years of relevant experience either administrative or with the company in another department with relevant knowledge. 
• Experience in healthcare operations, claims, customer service, grievances, appeals, complaints, utilization management, or related healthcare functions preferred.
• Knowledge of Medicare, Commercial Health Insurance, CMS, NCQA, and regulatory requirements preferred.

The extras:

• Bachelor's degree preferred in Healthcare Administration, Business Administration, or a related field; equivalent combination of education and relevant experience may be considered.

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
   

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit  www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.