Claims Customer Service Advocate II

Bluecross Blueshield Of South Carolina Columbia , SC 29209

Posted 3 weeks ago

Summary

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.

Description

  • 45% Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
  • 45% Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining 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.
  • 10% Identifies 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. Identifies and reports potential fraud and abuse situations.

Required Education:

  • High School Diploma or equivalent.

Required Work Experience:

  • Two (2) years of customer service experience including one (1) year claims or appeals processing OR
  • Bachelor's Degree in lieu of work experience.

Required Skills and Abilities:

  • 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.

Preferred Work Experience:

  • One year of MMIS and LiveOps experience (can be concurrent).

Preferred Software and Tools:

  • Microsoft office.

Work Environment:

  • Typical office environment.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

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Claims Customer Service Advocate II

Bluecross Blueshield Of South Carolina