Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

The Claims Customer Service Advocate II responds to customer inquiries, which may be non-routine and require adapting standard screens, scripts, and procedures or conducting research. The position reviews and adjudicates claims and/or non-medical appeals and determines whether to return, deny, or pay claims according to organizational policies and procedures. This is a full-time, 40-hour-per-week position with National Alliance, a BlueCross BlueShield of South Carolina subsidiary. The role is based at 4101 Percival Road in Columbia, South Carolina, in a typical office environment. Employees must be flexible to work any scheduled eight-hour shift between 11:30 a.m. and 8:00 p.m., Monday through Friday. Training is Monday through Friday, 8:00 a.m. to 4:30 p.m., for approximately six to eight weeks. The role may be reviewed for work-at-home eligibility after equipment issuance, training completion, a performance review, and evaluation of line-of-business needs. 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.
Microsoft Office skills.

Nice To Haves

Associate degree.
Two years of claims processing or call center experience.
Knowledge of word processing, spreadsheet, and database software.

Responsibilities

Respond accurately, promptly, and courteously to customer inquiries by telephone, in writing, on the web, or in person.
Handle situations that require adapting a response or conducting extensive research.
Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
Examine and process claims and/or non-medical appeals according to business and 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.
Identify complex complaints and inquiries that cannot be resolved using desk procedures and guidelines, and refer them to a lead or manager.
Identify and report potential fraud and abuse situations.