Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina-posted about 19 hours ago
Full-time • Mid Level
Onsite • Columbia, SC
5,001-10,000 employees
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Summary 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. Description Location : This position is full time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility to work any of our 8-hour scheduled shifts during the hours of 8:00 AM –6:00 PM. Training will be Monday – Friday 8:00 AM - 4:30 PM for approximately 6-8 weeks. This role is located on site at 4101 Percival Road, Columbia SC.

  • Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
  • Handles situations which may require adaptation of response or extensive research.
  • Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
  • Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
  • Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
  • Ensures claims are processing according to established quality and production standards.
  • Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
  • Identifies and reports potential fraud and abuse situations.
  • Required Education : High School Diploma or equivalent
  • Required Work Experience: 2 years of customer service experience including 1 year of claims or appeals processing experience 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 Tools: Microsoft office
  • Subsidized health plans, dental and vision coverage
  • 401K retirement savings plan with company match
  • Life Insurance
  • Paid Time Off (PTO)
  • On-site cafeterias and fitness centers in major locations
  • Wellness program and healthy lifestyle premium discount
  • Tuition assistance
  • Service recognition
  • Employee Assistance
  • Discounts to movies, theaters, zoos, theme parks and more
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