Claims Customer Service Advocate II

BlueCross BlueShield of South Carolina•Columbia, SC

5d•Onsite

About The Position

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. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: 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. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. This role is located on-site at 17 Technology Circle, Columbia, SC 29203. Overtime is required. Sponsorship: This position is not eligible for sponsorship now or in the future.

Requirements

High School Diploma or equivalent
2 years of customer service experience including 1-year claims or appeals processing OR 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.

Nice To Haves

Previous call center experience.
Previous claims experience.

Responsibilities

Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
Handle situations which may require adaptation of response or extensive research.
Identify incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
Ensure claims are processing according to established quality and production standards.
Identify 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.
Identify and report potential fraud and abuse situations.