Customer Service Advocate III

Description

Location: Full-time (40-hours/week) Monday-Friday in a typical office environment. Schedules include an 8-hour shift during normal business hours 8:30am-5pm. Occasional overtime may be required. The role is located onsite at 4101 Percival Road, Columbia SC.

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 identify cause and find ways to prevent and correct such causes.
• Identifies and reports potential fraud and abuse situations.
• 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 verifying correct coding of procedures and diagnosis codes.
• Ensures claims are processed according to established quality and production standards.
• Provides feedback to management regarding customer issues.
• Maintains accurate records concerning issues.
• Follows through on complaints until resolved or reports to management as needed.
• Maintains knowledge of procedures and policies.
• Aids in process improvements by recommending improvements in procedures and policies.
• Assists in training claims customer service representatives.