Claims Customer Service Advocate II

Summary

We are currently hiring for a Claims Customer Service Advocate II to join CGS/Blue Cross Blue Shield of South Carolina. You will be 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.

Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast.

We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

CGS

Location:

This position is a full time (40 hours/week) Monday-Friday in a typical office environment. This is a hybrid position. 3 days will be in the office and 2 days will be remote. This role is located at 26 Century Blvd Suite 610, Nashville, TN 37214.

• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handles situations which may require adaptation of response or extensive research.
• Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
• 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.
• Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
• Identifies and reports potential fraud and abuse situations.

High School Diploma or equivalent

2 years of customer service experience including 1 year claims or appeals processing 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 proficiency.
• Ability to handle confidential or sensitive information with discretion.

Microsoft Office.

We offer our employees great benefits and rewards. 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

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