- Where
- Columbia, South Carolina
- Level
- Senior
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
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:
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.
Location:
This position is full-time (40 hours/week) Monday through Friday in a typical office environment or home environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00 AM - 5:00 PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located on-site at 4101 Percival Road, Columbia, SC . Training will be onsite Monday-Friday 8:00 AM -4:30PM for approximately 8-10 weeks.
Sponsorship : This position is not eligible for sponsorship now or in the future.
What You’ll 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'll Need the Following:
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…