Claims Customer Service Advocate II

About This Role

This role involves responding to customer inquiries, performing research to resolve complex issues, and adjudicating claims or non-medical appeals according to policies and procedures for BlueCross BlueShield of South Carolina.

Responsibilities

• Respond accurately, timely, and courteously to telephone, written, web, or walk-in customer inquiries
• Handle situations requiring adaptation of response or extensive research
• Identify incorrectly processed claims and perform adjustments and reprocessing actions
• Examine and process claims and/or non-medical appeals according to regulations and guidelines
• Enter claims into the claim system after verifying correct coding of procedures and diagnosis codes
• Ensure claims are processed according to established quality and production standards
• Identify and refer complex complaints and inquiries to a lead or manager for resolution
• Identify and report potential fraud and abuse situations

Requirements

• High School Diploma or equivalent
• 2 years of customer service experience including 1 year 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 proficiency

Qualifications

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

Skills

* Required skills

Benefits