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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

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.

Required Education:
High school diploma or equivalency.

Degree 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:
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 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

Required Licenses and Certificates:
Work Environment:
Typical office environment.
On-site Position
Monday - Friday 8am -8pm
Mandatory Overtime within October - March (to include some evenings and weekend hours)

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

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 abilities@bcbssc.com 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.

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