Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

3d•Hybrid

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. This position is full-time (40 hours/week) Monday through Friday in a typical office environment. Employees are required to have the flexibility to work any 8-hour shift scheduled between the hours of 8:00 AM - 5:00 PM. Training will be onsite at Monday-Friday 8:00 AM -5 PM for approximately 8-10 weeks. This role is located on-site at 4101 Percival Road, Columbia SC. This role is HYBRID and W@H will be considered after onsite training, performance and LOB needs. Sponsorship: This position is not eligible for sponsorship now or in the future.

Requirements

High School Diploma or equivalent
2 years of customer service experience including 1 year of claims or appeals processing experience 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

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.
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 reports potential fraud and abuse situations.