Claims Customer Service Advocate III

BlueCross BlueShield of South Carolina•Columbia, SC

8d•Onsite

About The Position

Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries. Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates complex or specialty claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures. Description Logistics: PGBA – one of BlueCross BlueShield's South Carolina subsidiary companies Location : This position is full-time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility work any our 8-hour shift scheduled during hours of 10AM –7PM due to contractual obligations. Training will be Monday – Friday 8:00 AM 5:00 PM for approximately 6-8 weeks. This role is located on site at 17 Technology Circle, Columbia SC Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements : BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act ( SCA ). Under the McNamara-O'Hara Service Contract Act (SCA), employees are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. What You’ll Do: Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed. Research to identifying underlying causes and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations. Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met. Handles situations that require adaptation of response or extensive research. 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. Provide feedback to management regarding customer issues. Maintain accurate records concerning issues. Follow through on complaints until resolved or report to management as needed. Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies. Assists in training claims customer service representatives.

Requirements

High School Diploma or equivalent
3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
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.

Nice To Haves

Previous call center or claims processing experience.

Responsibilities

Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
Research to identifying underlying causes and determine ways to prevent and correct such causes.
Identifies and reports potential fraud and abuse situations.
Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met.
Handles situations that require adaptation of response or extensive research.
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.
Provide feedback to management regarding customer issues.
Maintain accurate records concerning issues.
Follow through on complaints until resolved or report to management as needed.
Maintain knowledge of procedures and policies.
Assist with process improvements by recommending improvements in procedures and policies.
Assists in training claims customer service representatives.