Claims Customer Service Advocate III

ourhrconnect; Columbia (SC); On-site; USD 38,000 - 54,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings plan with  公司匹

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

National Alliance is seeking a detail-oriented Customer Service/Claims Specialist to respond to complex inquiries, review claims and appeals, and adjudicate issues in alignment with contract standards. You will research underlying causes, identify prevention measures, and handle sensitive information with discretion.

In this role, you will enter claims into our system, ensure accurate coding, and maintain quality and productivity.

Qualifications

• 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
• High School Diploma or equivalent.
• Good verbal and written communication skills; Strong customer service skills; Basic business math; Ability to handle confidential information.

Responsibilities

• Review claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
• Research to identify underlying causes, and determine ways to prevent and correct such causes.
• Identifies and reports potential fraud and abuse situations.
• Research and respond 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.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensure claims are processed 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.

Skills

Customer service

Communication skills

Education

High School Diploma

Tools

Microsoft Office

Job description

Summary

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

National Alliance - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location

• 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 -8:00 PM.
• Training will be Monday - Friday 8:00 AM - 4:30 PM for approximately 6-8 weeks.
• Located at 4101 Percival Road, Columbia SC.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You Will Do:

• Review claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
• Research to identify underlying causes, and determine ways to prevent and correct such causes.
• Identifies and reports potential fraud and abuse situations.
• Research and respond 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.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensure claims are processed 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.

To Qualify For This Position, You Will Need:

• Required Work Experience: 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
• Required Education: High School Diploma or equivalent.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office.

Our Comprehensive Benefits Package Includes The Following:

• 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.
• Education Assistance.
• Service Recognition.
• National discounts to movies, theaters, zoos, theme parks and more.

What We Can Do for You:

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.

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations