Claims Customer Service Advocate III

About the role

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.

Responsibilities

• 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 policies.
• Assist with process improvements by recommending improvements in procedures and policies.
• Assists in training claims customer service representatives.

Requirements

Required Work Experience: 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.

Required Education: High School Diploma or equivalent.

Skills

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.

Required Software and Other Tools: Microsoft Office.

Preferred Qualifications

Bluechoice claims processing experience.

Benefits

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

Schedule

Location: This position is full-time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility to work any 8-hour shift scheduled during hours of 8am - 6pm due to contractual obligations. Training will be Monday – Friday 8:00 AM to 5:00 PM for approximately 6-8 weeks. This role may transition to work‑at‑home (W@H) after performance review and LOB needs. Onsite training of 6-8 weeks prior to consideration of W@H placement without Bluechoice experience. Sponsorship: This position is not eligible for sponsorship now or in the future.