Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

3d•Onsite

About The Position

The Claims Customer Service Advocate II responds to customer inquiries that may be non-routine and require adaptation of standard screens, scripts, or procedures. The role researches and resolves inquiries, reviews and adjudicates claims and/or non-medical appeals, and determines whether claims should be returned, denied, or paid in accordance with organizational policies and procedures. This is a full-time, on-site position at 4101 Percival Road in Columbia, South Carolina, working 40 hours per week, Monday through Friday, in a typical office environment. The regular eight-hour shift is scheduled during normal business hours of 8:00 AM to 4:30 PM. Occasional overtime may be necessary, and travel between buildings may be required. Training takes place on-site, Monday through Friday, from 8:00 AM to 5:00 PM for approximately 8–10 weeks. The position is not eligible for sponsorship now or in the future.

Requirements

High school diploma or equivalent.
Two years of customer service experience, including one year of claims or appeals processing experience, or a 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.
Proficiency with Microsoft Office.

Responsibilities

Respond accurately, promptly, and courteously to customer inquiries received by telephone, in writing, on the web, or in person.
Adapt responses and conduct extensive research when situations require it.
Identify incorrectly processed claims and perform adjustments and reprocessing according to department guidelines.
Examine and process claims and/or non-medical appeals according to business or contract regulations, internal standards, and examining guidelines.
Enter claims into the claim system after verifying correct procedure and diagnosis coding.
Ensure claims are processed according to established quality and production standards.
Refer complex complaints and inquiries that cannot be resolved using desk procedures and guidelines to a lead or manager.
Identify and report potential fraud and abuse situations.