SENIOR CLIENT SERVICES REPRESENTATIVE

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 our Monday – Friday 8-hour shift scheduled during hours of 8:00 AM – 5:00 PM. Training will be Monday – Friday 8:30 AM -4:30 PM 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, 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.
• 3 years of customer service experience, including 1 year of claims or appeals processing experience; 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 abilities.
• Ability to handle confidential or sensitive information with discretion.
• Microsoft Office

We Prefer:

• Candidates with customer service and provider Experience
• Candidates that will be able to handle and assist with escalation calls.

Work Environment:

• Typical office environment

What We Can Do for You:

Our comprehensive benefits package includes:

• 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

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. 

Management will be conducting interviews with the most qualified candidates, with prioritization give to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information. 

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.