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
 

Logistics:

This is a full-time position working Saturday-Sunday 8:00am – 8:00pm working on-site at Government Programs Complex, 17 Technology Circle, Columbia SC 29203, in an office environment.

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.

• Researches 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:

• High School Diploma

• 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 everchanging supplement benefits such as: dental, vision, fitness, over the counter, hearing, and tele-health.

• Must be knowledgeable of medical management processes to include investigating gap closures, at-home diabetic testing, and at-home colon screenings.

• One 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

What We can Do for You:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits 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

• Wellness program and healthy lifestyle premium discount

• Tuition assistance

• Service recognition

• Employee Assistance

• Discounts to movies, theaters, zoos, theme parks and more

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure your meet the qualifications.  This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. If the qualifications required proof of semester hours, please attach your transcript to your application.

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.