Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

3d•Onsite

About The Position

We are currently hiring for a Claims Customer Service Advocate II to join BlueCross BlueShield of South Carolina. You will be 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. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Job Description Position Purpose: This role is part of an inbound call center and directly helps our customers by responding to inquiries that may be non-routine and require deviation from standard screens, scripts and procedures. Research may be required to resolve these inquiries. Other responsibilities include review and adjudication of claims and/or non-medical appeals, determining whether to return, deny or pay claims while following policies and procedures. Location: This position is full-time (40 hours/week) Monday - Friday in a typical office environment. Employees are required to work a training and work schedule of 8:00am to 4:30. It may be necessary, given the business need to work occasional overtime and weekends. This role is located at 4101 Percival Road, Columbia SC. What You'll Do: You'll ensure effective customer relations by responding accurately, timely and courteously to our customers. These responses may be by telephone, written, web or walk-in inquiries. You will handle situations which may require a different set of responses or extensive research. Adhering to department guidelines, you will also identify claims that have been incorrectly processed and will enact process adjustments and reprocessing actions. You will examine and process claims and/or non-medical appeals while ensuring business/contract regulations, internal standards and examining guidelines. Another responsibility is to enter claims into the claim system after verifying correct coding of procedures and diagnosis codes. Claims must be processed according to established quality and production standards. You'll identify complaints and inquiries that may be complex and that cannot be resolved following usual procedures and guidelines and refer to a team lead or manager for resolution. You will also identify and report 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.

Nice To Haves

Provider Customer Service Experience

Responsibilities

You'll ensure effective customer relations by responding accurately, timely and courteously to our customers.
These responses may be by telephone, written, web or walk-in inquiries.
You will handle situations which may require a different set of responses or extensive research.
Adhering to department guidelines, you will also identify claims that have been incorrectly processed and will enact process adjustments and reprocessing actions.
You will examine and process claims and/or non-medical appeals while ensuring business/contract regulations, internal standards and examining guidelines.
Another responsibility is to enter claims into the claim system after verifying correct coding of procedures and diagnosis codes.
Claims must be processed according to established quality and production standards.
You'll identify complaints and inquiries that may be complex and that cannot be resolved following usual procedures and guidelines and refer to a team lead or manager for resolution.
You will also identify and report fraud and abuse situations.