Processor, Claims II

ourhrconnect; Nashville (TN); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking a claims adjudicator in Nashville to review complex or specialty claims and determine pay, denial, or return decisions. The role supports training and mentoring new staff within a full-time office environment.

The position requires strong organizational and analytical skills, plus proficiency in Microsoft Office. You will work with internal teams to ensure accurate coding and timely resolution of claims.

Qualifications

• Requires High School Diploma or equivalent.
• 2 years of experience processing, researching and adjudicating claims.
• Strong organizational, analytical and judgment skills; solid communication and math abilities.

Responsibilities

• Examines and processes complex or specialty claims according to regulations and guidelines.
• Enters claims into the system after verification of coding and accuracy.
• Resolves issues by researching policy and contacting internal teams as needed.

Skills

Organizational skills

Analytical skills

Judgment

Communication skills

Spelling/grammar

Basic business math

Discretion with sensitive info

Education

High School Diploma or equivalent

Tools

Microsoft Office

Job description

Summary

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members.

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:

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members.

Logistics:

CGS (cgsadmin.com) - 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. You will work an 8-hour shift scheduled during our normal business hours of 8:00am-4:00pm CST. This role is located at 26 Century Blvd Suite ST610 Nashville, TN 37214.

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 cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

Sponsorship:

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

What You'll Do:

• Examines and processes complex or specialty claims 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. Verifies that claims have been keyed correctly.
• Ensures that claims are processing according to established quality and production standards. Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
• Researches and resolves claims edits and deferrals. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas. Responds to routine correspondence and completes spreadsheet if applicable.

To Qualify for This Position, You'll Need the Following:

• Required Education: High School Diploma or equivalent
• Required Work Experience: 2 years of experience processing, researching and adjudicating claims.
• Required Skills and Abilities:Strong organizational, analytical and judgment skills.Strong oral and written communication skills.Proficient in spelling, punctuation and grammar.Proficient in basic business math.Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.

We Prefer That You Have the Following:

• Preferred Work Experience: 2 years of claims processing experience.
• Preferred Skills and Abilities:Strong time management skills.Strong attention to detail skills.Knowledge of mathematical and statistical concepts.
• Preferred Software and Other Tools: Proficient in word processing and spreadsheet applications. proficient database software skills.

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 op