Summary

Responsible for responding to routine Medicare Advantage inquiries. Identifies incorrectly processed Medicare claims and completes adjustments and related reprocessing actions. Reviews and adjudicates Medicare claims and/or non-medical appeals. Determines whether to return, deny or pay Medicare claims following organizational policies and procedures.

Description

Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. This role is located on-site at 4101 Percival Rd, Columbia, SC 29229

What You’ll Do:

• Using a variety of websites, responds to written and/or telephone inquiries from members, providers, and brokers. Answers a variety of questions according to desk procedures, ensuring that federal contract standards and objectives for timeliness, productivity, and quality are met. Accurately documents inquiries. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines. Research Center for Medicare and Medicaid Services (CMS) Local and National Coverage determinations for the reason a health claim was denied or paid.
• 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.
• Identifies complaints and inquiries of a complex level that cannot be resolved following a review of the various federal websites, desk procedures, and guidelines and refers these to a lead or manager for resolution. Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.

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

• Required Education:
• High School Diploma or equivalent.
• Required Work Experience:
• 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.
• Required Specialized Training:
• 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.

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 handle confidential or sensitive information with discretion.

Required Software and Other 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 for 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
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

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 our recruiter to verify resume specifics and salary requirements.

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 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.

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