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 research or adaptation of standard screens, scripts, and procedures. The role reviews and adjudicates claims and non-medical appeals and determines whether claims should be returned, denied, or paid in accordance with organizational policies and procedures. The position ensures effective customer relations by responding accurately, promptly, and courteously to telephone, written, web, or walk-in inquiries. It examines and processes claims and non-medical appeals under applicable business and contract regulations, internal standards, and examining guidelines; enters claims into the claim system after verifying procedure and diagnosis coding; and works to meet quality and production standards. The role also identifies incorrectly processed claims, makes adjustments and reprocessing actions, escalates complex issues that cannot be resolved using desk procedures, and reports potential fraud and abuse. This is a full-time position of 40 hours per week, Monday through Friday, at 4101 Percival Road, Columbia, South Carolina, in a typical office environment. Employees must be flexible to work scheduled eight-hour shifts between 10:00 a.m. and 6:30 p.m. Training is Monday through Friday, 8:00 a.m. to 4:30 p.m., for approximately six to eight 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.

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, timely, and courteously to telephone, written, web, and walk-in customer inquiries, including situations requiring adaptation or extensive research.
Research and resolve customer inquiries.
Review and adjudicate claims and non-medical appeals, determining whether to return, deny, or pay claims under organizational policies and procedures.
Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
Examine and process claims and 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.
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.