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 situations that may require deviation from standard screens, scripts, and procedures. The role performs research to resolve inquiries and reviews and adjudicates claims and/or 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 at 4101 Percival Road in Columbia, South Carolina, scheduled Monday through Friday for 40 hours per week. The regular eight-hour shift falls within 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 role 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, timely, and courteously to telephone, written, web, or walk-in inquiries.
Handle situations that may require adapting responses or conducting extensive research.
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.
Identify complex complaints and inquiries that cannot be resolved using desk procedures and guidelines, and refer them to a lead or manager.
Identify and report potential fraud and abuse situations.