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, including non-routine inquiries that may require adapting standard screens, scripts, and procedures or conducting extensive research. The role reviews and adjudicates claims and non-medical appeals, determining whether claims should be returned, denied, or paid in accordance with organizational policies and procedures. This is a full-time, on-site position in a typical office environment at 4101 Percival Road in Columbia, South Carolina. The schedule is Monday through Friday, 40 hours per week, with an eight-hour shift 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 is on-site Monday through Friday, 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.
Microsoft Office skills.

Responsibilities

Respond accurately, promptly, and courteously to telephone, written, web, or walk-in customer inquiries.
Adapt responses and conduct extensive research to resolve customer situations when needed.
Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
Examine and process claims and non-medical appeals in accordance with 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.