Service Advocate V – Appeals, Disputes

GuideWell Source

Service Advocate V handling appeals and disputes at Florida Blue. Review requests and resolve grievances following regulatory guidelines.

Posted 7/30/2026full-timeRemote • Florida • 🇺🇸 United StatesMid-LevelSenior💰 $20 - $33 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in reviewing and resolving appeals, grievances, and disputes while adhering to regulatory guidelines and corporate policies. Proficient in utilizing various claim payment systems and SQL databases to document and communicate determinations effectively.

Highest-signal resume keywords

Appeals ResolutionClaimCheck® Payment ConceptsSQL Database ManagementRegulatory ComplianceCustomer Interaction

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Claims ProcessingMedical Necessity ReviewData EntryRegulatory Guidelines KnowledgeMicrosoft Office Suite

Soft Skills

Professional CommunicationProblem SolvingTime Management

Tools & Technologies

BCBSF SystemsSQL DatabasesLegacy SystemsDiamondSiebel

Industry Keywords

ERISAHIPAAFee for ServiceUtilization ManagementGrievance Procedures

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Reviews appeal requests from members and providers in accordance with BCBSF policies and procedures, regulatory guidelines, and timelines. (15%)
Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, ClaimCheck®, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business except SAO & FEP. (15%)
Researches and resolves provider data loads. (5%)
Locates medical records and form CMS-1500 on Enterprise Imaging or Imaginator for clinical review or to verify proper coding (modifiers and procedure codes). (10%)
Accesses various web-based and other applications to review how claim was originally paid by BCBSF. (5%)
Researches and documents all issues and findings. (5%)
Enters appeal or dispute determinations into various BCBSF systems and SQL databases. (5%)
Follows regulatory requirements as appropriate and corporate values, policies and procedures. (15%)
Ensures final determination with statement that supports determination is communicated to provider within required timelines. (5%)
Completes customized correspondence with appropriate statement that supports final determination. (5%)
Follows strict timelines for communicating final determination. (5%)
Documents final disposition of dispute into BCBSF systems and SQL databases (5%)
Facilitates escalated calls and issues from providers and members regarding appeals or dispute decisions. (5%)

Requirements

What you’ll need

3+ years related work experience combination of transferable experience and education
High school diploma or GED
Experience using Microsoft Office, including Word, Excel and PowerPoint
Experience using BCBSF's member benefit booklets, reimbursement, medical necessity, fee for service and ClaimCheck® payment concepts, practices, and procedures
Experience using various inquiry and claim payment systems (e.g., Legacy, Diamond, Siebel, PIP, TSO, Convergence, Medical Coverage Guidelines, CMCA, MBSP, etc.) to research grievance, appeals or disputes
Experience entering grievance, appeal or dispute determinations into various BCBSF systems and SQL databases
Ability to follow regulatory requirements as appropriate and corporate values, policies and procedures
Demonstrated ability to interact with internal and external customers in a highly professional manner
Knowledge of ERISA and HIPAA
Knowledge of regulatory agency requirements, as appropriate
Ability to work within strict timeframes.

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Income protection benefits: life insurance, short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off, volunteer time off, 10 holidays and 2 well-being days
Additional voluntary benefits available; and a comprehensive wellness program