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Claims Customer Service Advocate III
BlueCross BlueShield of South Carolina. Provide prompt, accurate, thorough, and courteous responses to complex customer inquiries .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims processing and customer service, with a strong focus on resolving complex inquiries and ensuring compliance with organizational policies. Proficient in identifying process improvements and maintaining high-quality standards in claims adjudication.
Highest-signal resume keywords
Claims Processing ExperienceCustomer Service SkillsVerbal And Written Communication SkillsMicrosoft Office ProficiencyBluechoice Claims Processing Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationAppeals ProcessingBusiness Math AbilitiesProcedure And Diagnosis CodingFraud DetectionQuality AssuranceProcess ImprovementIssue Resolution
Soft Skills
Attention To DetailDiscretion With Confidential InformationCustomer Inquiry Resolution
Industry Keywords
Claims SystemNon-Medical AppealsOrganizational PoliciesInternal StandardsCustomer Complaints
About the role
Key responsibilities & impact- Provide prompt, accurate, thorough, and courteous responses to complex customer inquiries
- Research and resolve non-routine inquiries requiring deviation from standard screens, scripts, and procedures
- Review and adjudicate complex or specialty claims and/or non-medical appeals
- Determine whether to return, deny, or pay claims according to organizational policies and procedures
- Review claims or appeals issues, complaints, and inquiries to determine whether desk procedures and guidelines were followed
- Research underlying causes and identify ways to prevent and correct them
- Identify and report potential fraud and abuse situations
- Examine and process claims and/or non-medical appeals according to business and contract regulations, internal standards, and examining guidelines
- Enter claims into the claims system after verifying procedure and diagnosis coding
- Ensure claims meet quality and production standards
- Provide feedback to management regarding customer issues and maintain accurate issue records
- Follow through on complaints until resolution or report them to management
- Maintain knowledge of procedures and policies
- Recommend process and policy improvements
- Assist in training claims customer service representatives
Requirements
What you’ll need- 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience
- High School Diploma or equivalent
- 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
- Microsoft Office
- Preferred Bluechoice claims processing experience
- Ability to work any 8-hour shift scheduled during 8:00 AM–6:00 PM, Monday–Friday
- Must not require sponsorship now or in the future
Benefits
Comp & perks- 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