Claims Customer Service Advocate II

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 Location: This position is full‑time (40‑hours/week) Monday‑Friday. Training will be on‑site from 8AM‑4:30PM and will require you to stay in house for the first 60 days before you can work remote. You will have the opportunity to work from 7:30AM‑4PM or 8AM‑4:30PM. What You'll Do Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk‑in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and 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. Enters 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. Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations. To Qualify For This Position, You'll Need The Following Required Education: High School Diploma or equivalent Required Work Experience: 2 years of customer service experience including 1‑year claims or appeals processing 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 proficiency. Ability to handle confidential or sensitive information with discretion. Required Software and Other Tools: Microsoft Office. Our Comprehensive Benefits Package Includes The Following We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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. 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 View email address on click.appcast.io or call View phone number on click.appcast.io 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. #J-18808-Ljbffr