Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

2d•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 and conducting research. The role reviews and adjudicates claims and/or non-medical appeals and determines whether claims should be returned, denied, or paid according to organizational policies and procedures. This is a full-time, on-site position at 4101 Percival Road in Columbia, South Carolina, working Monday through Friday in a typical office environment. The regular schedule is an eight-hour shift during business hours of 8:00 AM–4:30 PM. Initial training is on-site, Monday through Friday, 8:00 AM–5:00 PM, for approximately 8–10 weeks. Occasional overtime may be necessary, and travel between buildings may be required. 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 customer inquiries by telephone, in writing, online, or in person.
Adapt responses or conduct extensive research to handle customer situations as needed.
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 that procedure and diagnosis codes are correct.
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.