Summary

Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions.

Description

• 60% Researches and responds to telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
• 20% Research and respond to written inquiries and identify incorrectly processed claims and completes the adjustment and/or reprocessing action according to department guidelines. This may include initiating, documenting, and processing the request to completion. Initiate recoupments as necessary.
• 10% Identifies complaints and inquiries of a complexity 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.
• 10% Completes projects and/or assignments related to claims processing and customer service functions in the department.

Required Work Experience:

• Two years of customer service experience OR
• One year of claims or appeals processing experience and One year of customer service experience OR
• Bachelor's Degree in lieu of work experience.

Preferred Work Experience:

• TRICARE experience within the last two years. (May be concurrent with other required experience.)

Required Education:

• High School Diploma or equivalent

Skills and Abilities:

• Answers phones
• Follows policies and procedures
• Navigates systems
• Processes claims
• Researches inquiries
• Reviews claims and appeals

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

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