Client Services Representative

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

Responsible for responding to routine Medicare Advantage inquiries. Identifies incorrectly processed Medicare claims and completes adjustments and related reprocessing actions. Reviews and adjudicates Medicare claims and/or non-medical appeals. Determines whether to return, deny or pay Medicare claims following organizational policies and procedures. Description Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. This role is located on-site at 4101 Percival Rd, Columbia, SC 29229 What You’ll Do: Using a variety of websites, responds to written and/or telephone inquiries from members, providers, and brokers. Answers a variety of questions according to desk procedures, ensuring that federal contract standards and objectives for timeliness, productivity, and quality are met. Accurately documents inquiries. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines. Research Center for Medicare and Medicaid Services (CMS) Local and National Coverage determinations for the reason a health claim was denied or paid. Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards, and examining federal guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensures claims are processing according to established quality and production standards. Identifies complaints and inquiries of a complex level that cannot be resolved following a review of the various federal websites, desk procedures, and guidelines and refers these to a lead or manager for resolution. Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.

Requirements

High School Diploma or equivalent.
1 year of experience in a claims/appeals processing, customer service, or other related support area; OR Bachelor's degree in lieu of work experience.
Overall understanding of CMS enrollment, disenrollment policies; must understand CMS Part D Drug Manual and processing guidelines to respond to pharmacy-related questions; must understand ITS rule and regulations ; must understand ever-changing supplemental benefits such as: dental, vision, fitness, over-the-counter, hearing, and telehealth; must be knowledgeable of medical management processes to include: investigating gap closures, at-home diabetic testing, and at-home colon screenings.
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.

Responsibilities

Using a variety of websites, responds to written and/or telephone inquiries from members, providers, and brokers.
Answers a variety of questions according to desk procedures, ensuring that federal contract standards and objectives for timeliness, productivity, and quality are met.
Accurately documents inquiries.
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Research Center for Medicare and Medicaid Services (CMS) Local and National Coverage determinations for the reason a health claim was denied or paid.
Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards, and examining federal guidelines.
Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
Ensures claims are processing according to established quality and production standards.
Identifies complaints and inquiries of a complex level that cannot be resolved following a review of the various federal websites, desk procedures, and guidelines and refers these to a lead or manager for resolution.
Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.