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Senior Client Services Representative

Company: BlueCross and BlueShield of South Carolina
Location: West Columbia
Posted on: June 12, 2021

Job Description:

SummaryProvides 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 govemental policies and procedures.Description40%Reviews claims or appeals issues, complaints, and inquiries referred by Member Services Representative to determine if desk procedures and federal guidelines were followed. Researches to identifying underlying causes and determines ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations. Responds to complex Medicare Part C and Part D questions, ensures CMS coordination of benefit reconciliation is accurate, and answers escalated provider inquires.20% Researches and responds 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.20% 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.10% 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.10% Maintains knowledge of procedures and policies. Assists with process improvements by recommending improvements in procedures and policies. Assists in training client services representatives.Required Education: High school diploma or equivalency.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 Work Experience: Three years of customer service experience, including one year of claims or appeals processing experienceORBachelor's degree in lieu of work experience.Required Skills and Abilities: 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.Required Software and Other Tools: Microsoft Office.Work Environment: Typical office environment.We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.Equal Employment Opportunity StatementBlueCross 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 or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

Keywords: BlueCross and BlueShield of South Carolina, Columbia , Senior Client Services Representative, Other , West Columbia, South Carolina

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