Job Description
TITLE: CLAIMS CUSTOMER SERVICE ADVOCATE II
LOCATION: COLUMBIA. SC 29219 (ONSITE)
DURATION: 12 MONTHS ASSIGNMENT
DUTIES
- 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.
- 45% 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.
- 45% 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.
- 10% 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.
SKILLS:
- Required Skills and Abilities: 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.
- Required Software and Other Tools: Microsoft Office.
- Work Environment: Typical office environment.
EDUCATION:
- Required Education: High School Diploma or equivalent Required Work Experience: 2 years of customer service experience including 1-year claims or appeals processing OR Bachelor's Degree in lieu of work experience.