Summary
 

We are currently hiring for a Senior Client Services Representative to join BlueCross BlueShield of South Carolina. You will provide prompt, accurate, thorough and courteous responses to all complex inquiries from Medicare Advantage members and providers. Inquiries are typically non-routine and require deviation from standard screens, scripts, government websites and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates complex or specialty Medicare claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational and governmental policies and procedures.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics:

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

What you will do:

• Reviews claims or appeals issues, complaints, and inquiries referred by Member Services Representative to determine if desk procedures and federal guidelines were followed.
• Research to identify underlying causes and determines ways to prevent and correct such causes.
• Identifies and reports potential fraud and abuse situations.
• Research and respond to complex customer inquiries, ensuring that contract standards and Federal and organizational 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 federal 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.
• Provides feedback to management regarding escalated customer issues.
• Maintains accurate records concerning issues. Follows through on complaints until resolved or report to management as needed.
• Maintains knowledge of procedures and policies.
• Assists with process improvements by recommending improvements in procedures and policies.
• Assists in training client services representatives.

To Qualify for this position, you will need:

• High School Diploma or equivalent
• Overall understanding of CMS enrollment, disenrollment policies; must understand CMS Part D Drug Manual and processing guidelines to respond to pharmacy-related questions; must understand ITS rule and regulations; must understand ever-changing supplemental benefits such as: dental, vision, f