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:
This is a full-time (40 hours/week) Monday - Friday work from home position.
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. Researches 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.
What You Need to Qualify:
- High School Diploma or equivalent.
- 3 years of customer service experience, including 1 year of claims or appeals processing experience 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 abilities.
- Ability to handle confidential or sensitive information with discretion.
- Microsoft Office.
What we Can Do For You:
You are not alone. We are here to support you.
Our comprehensive benefits package includes:
- 401 (k) retirement savings plan with company match.
- Subsidized health plans and free vision coverage.
- Life Insurance.
- Paid annual leave - the longer you work here, the more you earn.
- Nine paid holidays.
- Tuition Assistance.
- Service Recognition.
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 a recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with the most qualified candidates, with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Here's
more information
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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 minorities, females, disabled individuals and 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 physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, 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.
