Claims Customer Service Advocate III
On-site · Columbia, South Carolina, United States
Job Summary
Claims Customer Service Advocate III provides prompt, accurate, thorough and courteous responses to complex customer inquiries and non-routine issues that require deviation from standard screens and procedures. The role reviews and adjudicates complex claims and non-medical appeals, determines whether to return, deny or pay claims following organizational policies, and researches underlying causes to prevent future issues. Responsibilities include researching and responding to complex inquiries, reporting potential fraud and abuse, entering and coding claims accurately, ensuring compliance with contract standards and quality metrics, maintaining accurate records, supporting process improvements, and assisting in training claims customer service representatives. The position emphasizes strong communication, confidentiality, and adherence to established standards while supporting the company’s benefits and service objectives.
Required Qualifications
- 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience
- High School Diploma or equivalent
- Good verbal and written communication skills
- Strong customer service skills
- Good spelling, punctuation, and grammar
- Basic business math abilities
- Ability to handle confidential or sensitive information with discretion
- Microsoft Office proficiency
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