Claims Customer Service Advocate II

TALENT Software Services; Columbia (SC); On-site; USD 38,000 - 52,000; Full time

Job summary

TALENT Software Services in Columbia, SC is seeking a customer service specialist to respond to inquiries, research issues, and adjudicate claims and non-medical appeals following established policies.

You will process claims, verify coding, maintain quality standards, assist with adjustments, and escalate complex cases to a lead or manager as needed.

Qualifications

• High School Diploma or equivalent.
• 2 years of customer service experience including 1 year claims/appeals processing, or Bachelor's degree in lieu of work experience.
• Strong verbal and written communication, and discretion with confidential information.
• Proficiency with Microsoft Office.

Responsibilities

• Respond to customer inquiries, researching as needed to resolve non-routine issues.
• Maintain effective customer relations by handling inquiries via phone, written, web, or walk-in with timely, courteous responses.
• Examine and process claims and non-medical appeals according to regulations and guidelines; enter claims with correct coding.
• Identify complex inquiries and refer to a lead/manager; report potential fraud or abuse.

Skills

Verbal communication

Written communication

Customer service

Discretion with information

Basic business math

Education

High School Diploma or equivalent

Tools

Microsoft Office

Job description

Duties

• 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.
• 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.

Skills

• 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 Other Tools: Microsoft Office.
• Work Environment: Typical office environment.

Required Education

High School Diploma or equivalent

Required Work Experience

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