Claims Customer Service Advocate III at BlueCross BlueShield of South Carolina

Columbia, South Carolina, United States -

Full Time

Start Date

Immediate

Expiry Date

13 Jun, 26

Salary

0.0

Posted On

15 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Customer Service, Claims Processing, Appeals Processing, Research, Adjudication, Fraud Detection, Communication, Problem Solving, Data Entry, Policy Adherence, Process Improvement, Training, Microsoft Office

Industry

Insurance

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 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 10AM –7PM due to contractual obligations. Training will be Monday – Friday 8:00 AM 5:00 PM for approximately 6-8 weeks. This role is located on site at 17 Technology Circle, Columbia SC 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). Under the McNamara-O'Hara Service Contract Act (SCA), employees are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. What You’ll Do: Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed. Research to identifying underlying causes and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations. Researches and responds 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. Examines and processes claims and/or non-medical appeals 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. Ensures claims are processing 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'll Need the Following: Required Education: High School Diploma or equivalent 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 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. We Prefer That You Have the Following: Previous call center or claims processing experience. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for the first of the month following 28 days of employment. 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. 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 our recruiter to verify resume specifics and salary requirements 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 mycareer.help@bcbssc.com 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. Here's more information. Some states have required notifications. Here's more information. If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit. PGBA, LLC is a leading provider of administrative services for the TRICARE health benefit program and health benefit programs of Veteran’s Health Administration for both state and federal governments. The company has offices in Florence, Surfside Beach, and Columbia, South Carolina. PGBA employees work in an atmosphere that is conducive to growth and on that fosters a focus on personal and professional development with an environment made up of people from different parts of the world with diverse cultural Excellent benefits, as well as a competitive compensation program, make us one of the leading employers in today’s corporate market.

Responsibilities

This role involves providing prompt, accurate, and courteous responses to complex customer inquiries that typically require deviation from standard procedures, alongside reviewing and adjudicating complex claims or non-medical appeals according to organizational policies.