Claims Customer Service Advocate III

001 BlueCross and BlueShield of South Carolina; Columbia (SC); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

Subsidized health plans

Dental and vision coverage

401k with company match

Life Insurance

Paid Time Off

Job summary

BlueCross BlueShield of South Carolina is seeking a detail-oriented Claims/Appeals Specialist to review complex inquiries and adjudicate claims according to policies. The role requires research, adherence to timelines, and collaboration with customer service to resolve issues.

The position is full-time in a typical office setting with standard business hours and training. Excellent communication and discretion are essential to succeed in this role.

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.
• Good verbal and written communication skills; strong customer service skills.
• Ability to handle confidential or sensitive information with discretion.

Responsibilities

• Review claims or appeals issues to determine if desk procedures and guidelines were followed.
• Research to identify underlying causes and determine preventive actions.
• Identify and report potential fraud and abuse situations.
• Research and respond to complex customer inquiries ensuring timeliness and quality.
• Examine and process claims and non-medical appeals according to regulations and guidelines.
• Enter claims into the system after verification of coding procedures and diagnoses.

Skills

Strong customer service

Good written communication

Attention to detail

Basic math skills

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 National Alliance – 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 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 do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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Welcome Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.