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.

What You'll Do

• Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handle situations which may require adaptation of response or extensive research.
• Identify 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.
• 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.
• 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.
• Identify and report 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 of claims or appeals processing experience 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 Tools: Microsoft Office

Benefits

• 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
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

Schedule

Full time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility to work any of our 8-hour scheduled shifts during the hours of 8:00 AM – 6:00 PM. Training will be Monday – Friday 8:00 AM - 4:30 PM for approximately 6-8 weeks. This role is located on site at 4101 Percival Road, Columbia SC.