Claims Customer Service Advocate II

at  Companion Data Services

Summary
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.
Description

What You Will Do:

• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handle situations which may require adaptation of response or extensive research.
• Identify incorrect processed claims, processes adjustments, reprocessing actions according to department guidelines.
• 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.
• Ensures claims are processing according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures, guidelines, and refers these to a lead or manager for resolution.
• Identify and reports potential fraud and abuse situations.

To Qualify for This Position, You Will Need:

• High School Diploma OR equivalent
• 2 years of customer service experience including 1 year of claims or appeals processing OR Bachelor’s Degree in lieu of work experience.
• 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.
• Microsoft Office

Logistics
This position is a typical office environment on-site, full time (40 hours/week) Shifts between 8AM – 6PM Monday-Friday
What to Expect Next
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.
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 have been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team!
Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
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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 minorities, females, disabled individuals and 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 physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, 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

• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handle situations which may require adaptation of response or extensive research.
• Identify incorrect processed claims, processes adjustments, reprocessing actions according to department guidelines.
• 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.
• Ensures claims are processing according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures, guidelines, and refers these to a lead or manager for resolution.
• Identify and reports potential fraud and abuse situations