Claims Customer Service Advocate I

BlueCross BlueShield of South Carolina•Myrtle Beach, SC

3d•Onsite

About The Position

Responsible for responding to routine inquiries. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures. PGBA – is a subsidiary company of BlueCross BlueShield of South Carolina. Location : This position is full-time (40 hours/week) Monday-Friday in a typical office environment. This position is located at 8733 Highway 17 Bypass Myrtle Beach, SC 29575. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements : BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act ( SCA ). Under the McNamara-O'Hara Service Contract Act (SCA), employees are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

Requirements

High School Diploma or equivalent
1 year of experience in claims/appeals processing, customer service, or other related support area OR Bachelor's Degree in lieu of work experience.
Good verbal and written communication skills
Strong customer service skills.
Good spelling, punctuation and grammar skills
Basic business math proficiency
Ability to handle confidential or sensitive information with discretion.
Microsoft office

Responsibilities

Responds to written and/or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
Accurately documents inquiries.
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
Ensure claims are processed according to established quality and production standards.
Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.