Client Services Representative

We have a job opening for the position Client Services Representative
at BlueCross BlueShield of South Carolina. In this role, you will be responsible for responding to routine Medicare Advantage inquiries, identifying incorrect processed Medicare claims, completing adjustments, and related reprocessing actions. You will review and adjudicate Medicare claims and/or non-medical appeals. In addition, you are asked to determine whether to return, deny or pay Medicare claims following organizational 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 have 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 committed 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.

• Using a variety of websites, respond to written and/or telephone inquiries from members, providers, and brokers.
• Answer a variety of questions according to desk procedures, ensuring that federal contract standards and objectives for timeliness, productivity, and quality are met.
• Accurately document inquiries.
• Identify incorrect processed claims, process adjustments, and reprocess actions according to department guidelines.
• Research Center for Medicare, Medicaid Services (CMS), and Local and National Coverage determinations for the reason a health claim was denied or paid.
• Examine and processes claims and/or non-medical appeals according to business/contract regulations, internal standards, and examining federal guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensure claims are processing according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following a review of the various federal websites, desk procedures, and guidelines and refer these to a lead or manager for resolution.
• Identify and promptly report and/or refer suspected fraudulent activities and system errors to the appropriate departments.

• High School Diploma or equivalent
• Degree Equivalency: None
• 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, fitness, over the counter, hearing, and telehealth; must be knowledgeable of medical management processes to include investigating gap closures, at-home diabetic testing, and at-home colon screenings.
• 1 year of experience in a claims/appeals processing, customer service, or other related support area; OR Bachelor's degree in lieu of work experience.
• 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.
• Microsoft Office

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.