SummaryProvides 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.
DescriptionLogistic: This position is full-time (40 hours/week), Monday through Friday, in a typical office environment located at 8733 Highway 17 Bypass, Myrtle Beach, SC 29575.
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 identifies underlying causes and determines 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. Handle 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 verifying the 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. Recommend procedures and policies to improve the process. Train claims customer service representatives.
To Qualify for This Position, You'll Need:- 3 years of customer service experience, including 1 year of claims OR appeals processing experience OR Bachelor's Degree in lieu of work experience.
- High school diploma or equivalent
- 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
Preferred Skill:TRICARE
What Blue Can Do For 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
- On-site cafeterias and fitness centers in major locations
- Wellness programs and a healthy lifestyle premium discount
- 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 our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, 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. Equal Employment Opportunity StatementBlueCross 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 ...@bcbssc.com or call 1-800-###-####, 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.