Claims Customer Service Advocate II

Overview

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.

This position is full time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility to work any of our 8-hour scheduled shifts during the hours of 8:00 AM –6:00 PM. Training will be Monday – Friday 8:00 AM - 4:30 PM for approximately 6-8 weeks. This role is located on site at 4101 Percival Road, Columbia SC.

• 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.
• 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.
• 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:
  
  2 years of customer service experience including 1 year of claims or appeals processing experience 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.
• Required Software and Tools:
  Microsoft Office

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage
• 401K retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Management will conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the required qualifications.

Blue Cross Blue Shield 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 individuals with disabilities and protected veterans.

It is our…