Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

19h•Onsite

About The Position

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.

Requirements

A High School Diploma or equivalent.
Two years of customer service experience, including one year of claims or appeals processing OR an undergraduate 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.
The ability to handle confidential or sensitive information with discretion.
Knowledge of Microsoft Office applications.

Nice To Haves

Demonstrate preferred qualifications.

Responsibilities

Ensure effective customer relations by responding accurately, timely and courteously to our customers via telephone, written, web or walk-in inquiries.
Handle situations which may require a different set of responses or extensive research.
Identify claims that have been incorrectly processed and enact process adjustments and reprocessing actions.
Examine and process claims and/or non-medical appeals while ensuring business/contract regulations, internal standards and examining guidelines.
Enter claims into the claim system after verifying correct coding of procedures and diagnosis codes.
Process claims according to established quality and production standards.
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.
Identify and report fraud and abuse situations.