Claims Customer Service Advocate III

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

Provides prompt, accurate, thorough, and courteous responses to complex customer inquiries, which are typically non-routine and may require deviation from standard screens, scripts, and procedures. Researches inquiries as needed and reviews and adjudicates complex or specialty claims and/or non-medical appeals. Determines whether claims should be returned, denied, or paid in accordance with organizational policies and procedures. This is a full-time, 40-hour-per-week, on-site position at 4101 Percival Rd, Columbia, SC 29229. The role follows a Monday-Friday schedule in a typical office environment. Training is scheduled from 8:00 AM to 4:30 PM, and work hours can fall between 8:30 AM and 5:00 PM. The role reviews claims and appeals issues, complaints, and inquiries referred by claims customer service representatives; researches causes and identifies ways to prevent or correct them; and identifies and reports potential fraud and abuse. It researches and responds to complex customer inquiries while meeting contract standards and objectives for timeliness, productivity, and quality. The position also processes claims and non-medical appeals, maintains issue records, follows complaints through resolution, provides feedback to management, recommends process improvements, and assists with training claims customer service representatives.

Requirements

Three years of customer service experience, including one year of claims or appeals processing experience, or a bachelor's degree in lieu of work experience.
High school diploma or equivalent.
Good verbal and written communication skills.
Strong customer service skills.
Good spelling, punctuation, and grammar skills.
Basic business math abilities.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office.

Responsibilities

Review claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine whether desk procedures and guidelines were followed.
Research underlying causes of issues and determine ways to prevent and correct them.
Identify and report potential fraud and abuse situations.
Research and respond to complex customer inquiries, including situations requiring adapted responses or extensive research.
Meet contract standards and objectives for timeliness, productivity, and quality.
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 correct procedure and diagnosis coding.
Ensure claims are processed according to established quality and production standards.
Provide management with feedback regarding customer issues and maintain accurate records.
Follow through on complaints until resolved or report them to management as needed.
Maintain knowledge of procedures and policies and recommend process improvements.
Assist with training claims customer service representatives.