Claims Customer Service Advocate III

BlueCross and BlueShield of South Carolina; Columbia (SC); On-site; USD 40,000 - 53,000; Full time

Benefits offered by this job

Health insurance

Benefits after 28 days

Job summary

BlueCross BlueShield of South Carolina in Columbia seeks a Customer Service Claims Specialist. You will provide prompt, accurate responses to complex inquiries, research issues, and adjudicate claims and appeals in line with policies.

This on-site, full-time role requires 3 years of customer service experience (1 year claims processing) or a Bachelor's degree, a high school diploma, and strong communication. Training is on-site; benefits begin after 28 days.

Qualifications

• 3 years of customer service experience, including 1 year in claims or appeals processing, OR a Bachelor's Degree in lieu of work experience.
• High School Diploma or equivalent required.
• Strong verbal and written communication; ability to handle confidential information with discretion.

Responsibilities

• Review claims or appeals and determine adherence to desk procedures; research causes and prevent recurrences.
• Research and respond to complex inquiries, ensuring timeliness, productivity and quality.
• Examine and process claims/ non-medical appeals per regulations and internal standards; enter into claims system.
• Provide feedback to management; maintain accurate records; follow up on complaints until resolved.
• Maintain knowledge of procedures; assist in training claims customer service representatives.

Skills

Verbal communication

Written communication

Customer service

Confidential information handling

Business math

Education

High School Diploma or equivalent

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

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

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.

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 9AM -6PM. Training will be Monday - Friday 8:00 AM - 4:30/5:00pm on site at the GPC Location. for approximately 6-8 weeks. This role is located on site at 17 Technology Circle, Columbia SC. Hours will not change due to contractual obligations.

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 ) . As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.

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

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, den