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.
- 40% 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
identifying underlying causes, and determine ways to prevent and
correct such causes. Identifies and reports potential fraud and
- 20% Researches and responds 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.
- 20% 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
- 10% Provide feedback to management regarding customer issues.
Maintain accurate records concerning issues. Follow through on
complaints until resolved or report to management as needed.
- 10% Maintain knowledge of procedures and policies. Assist with
process improvements by recommending improvements in procedures and
policies. Assists in training claims customer service
Required Work Experience:
- Three years of customer service experience, including one year
of claims or appeals processing experience OR
- Bachelor's Degree in lieu of work experience.
- High School Diploma or equivalent
Required Skills and Abilities:
- 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
Required Software and Other Tools:
- Typical office environment.
We participate in E-Verify and comply with the Pay Transparency
Nondiscrimination Provision. We are an Equal Opportunity
Equal Employment Opportunity Statement
BlueCross 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
If you need special assistance or an accommodation while seeking
employment, please e-mail email@example.com or call
1-800-288-2227, ext. 43172 with the nature of your request. We will
make a determination regarding your request for reasonable
accommodation on a case-by-case basis.