Summary
 

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.

Description
 

Location:

This position is full-time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility work any our 8-hour shift scheduled during hours of 8:00 AM –8:00 PM. Training will be Monday – Friday 8:00 AM – 4:30/5:00PM PM for approximately 6-8 weeks. This role is located on site at 4101 Percival Road, Columbia SC

What You’ll Do:

• Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed. Research to identifying underlying causes and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.
• 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.
• 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.
• Provide feedback to management regarding customer issues. Maintain accurate records concerning issues. Follow through on complaints until resolved or report to management as needed.
• Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies. Assists in training claims customer service representatives.

To Qualify for This Position, You’ll Need the Following:

• Required Education:
• A High School Diploma or equivalent
• Required Work Experience:
• 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
• 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 Manage Confidential or Sensitive Information with Discretion.
• Required Software and Tools:
• Microsoft Office.

Our comprehensive benefits package includes the following:

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
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts