Summary
 

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members.

Description
 

• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Verifies that claims have been keyed correctly.
• Ensures that claims are processing according to established quality and production standards. Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
• Researches and resolves claims edits and deferrals. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas. Responds to routine correspondence and completes spreadsheet if applicable.
• Required Education:
• High School Diploma or equivalent
• Required Work Experience:
• 2 years of experience processing, researching and adjudicating claims.
• Required Skills and Abilities:
• Strong organizational, analytical and judgment skills.
• Strong oral and written communication skills.
• Proficient in spelling, punctuation and grammar.
• Proficient in basic business math. 
• Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools:
• Microsoft Office.
• Preferred Work Experience: 
• 5 years-of experience processing and adjudicating claims.
• Preferred Skills and Abilities: 
• Strong time management skills. Knowledge of mathematical and statistical concepts.
• Preferred Software and Other Tools: 
• Proficient in word processing and spreadsheet applications.
• Proficient database software skills.
• Work Environment: 
• Typical office environment.       

 

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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.