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
 

Logistics: This position is full-time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have the flexibility to work any of our 8-hour shift scheduled during our normal business hours. It may be necessary, given the business need to work occasional overtime and weekends. This role is located at 17 Technology Circle, Columbia SC 29203. 

What You'll Do:

From the moment you log in, you'll be focused on proactively resolving our members' and/or providers' questions and concerns using computer-based resources to find answers—communication via telephone, written, web, or walk-in inquiries. You will guide members and providers with their healthcare needs by explaining benefits, solving claim concerns, and helping find a doctor via telephone calls, online chats, or e-mails. At times, extensive research may be needed, and it may be necessary to collaborate with other departments to find the answers needed. Accurately documenting these questions is vital for the success of this role. You are the subject matter expert for this role. Your leadership team is open to your recommendations, feedback, process improvements, and assistance with special projects to make positive changes for the department. Once you have mastered this role, training and sharing your knowledge with new team members can be a rewarding part of this role.

• Researches and responds to telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.

• 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.

• 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.

• Completes projects and/or assignments related to claims processing and customer service functions in the department.

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To Qualify for This Position, You'll Need:

• A High School Diploma or equivalent.

• Excellent verbal and written communication skills, including proficiency in spelling, grammar, and punctuation.

• Strong human relations and organizational skills, with a demonstrated ability to handle high-stress, intense situations and conversations.

• Good judgment and the ability to handle confidential or sensitive information with discretion.

• Ability to learn.

We Prefer That You Have:

• Two years of customer service experience 1 year of claims or appeals processing experience and one year of customer service experience or a bachelor's degree in lieu of work experience is preferred.

What We Can Do for You:

You are not alone. We are here to support you:

Six weeks of training, including:

• Best-in-class call center training program.

• Peer coach to observe you.

• Peer coach for you to observe.

• Open di