- 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.
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 9AM –6PM. Training will be Monday – Friday 8:00 AM - 4:30/5:00pm on site at the GPC Location. for approximately 6-8 weeks. This role is located on site at 17 Technology Circle, Columbia SC. Hours will not change due to contractual obligations.
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 ) . As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.
Sponsorship : This position is not eligible for sponsorship now or in the future.
What You Will 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…