Claims Customer Service Advocate III

BlueCross BlueShield of South Carolina•Columbia, SC

4d•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. The role is with National Alliance, a subsidiary company of BlueCross BlueShield of South Carolina. It is a full-time, 40-hour-per-week position, Monday through Friday, in a typical office environment at 4101 Percival Road, Columbia, South Carolina. Employees must be flexible to work scheduled eight-hour shifts between 8:00 AM and 8:00 PM. Training is Monday through Friday, 8:00 AM to 4:30 PM, for approximately six to eight weeks. The position is not eligible for sponsorship now or in the future.

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 skills.

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 or correct them.
Identify and report potential fraud and abuse situations.
Research and respond to complex customer inquiries while meeting contract standards and objectives for timeliness, productivity, and quality.
Handle situations requiring adapted responses or extensive research.
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 of issues.
Follow through on complaints until resolved or report them to management as needed.
Maintain knowledge of procedures and policies.
Recommend improvements to procedures and policies and assist with process improvements.
Assist in training claims customer service representatives.