Claims Customer Service Advocate II-2

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures. Description Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. This role is located on-site at 4101 Percival Rd, Columbia, SC 29229 What You’ll Do: Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines. Examine 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. Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.

Requirements

Required Education: High School Diploma or equivalent
Required Work Experience: 2 years of customer service experience including 1-year claims or appeals processing OR Bachelor's Degree in lieu of work experience.
Required Skills and Abilities: 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.
Required Software and Other Tools: Microsoft Office.

Responsibilities

Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
Handles situations which may require adaptation of response or extensive research.
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Examine 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.
Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution.
Identifies and reports potential fraud and abuse situations.

Benefits

We offer our employees great benefits and rewards.
You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more