Advocate

• 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%)

Service Advocate V handling appeals and disputes for Florida Blue

Service Advocate V – Appeals, Disputes

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

• Provides outstanding support to inbound callers regarding Health Spending Account, COBRA, Retiree or Exchange inquiries and requests.
• Assists with enrollment related to Health Spending Account, COBRA, Retiree or Exchange programs
• Answer inbound calls professionally, with high energy and a positive attitude and a little charm.
• Respond accurately and thoroughly to caller inquiries and document call details accordingly.
• Ensure compliance in all areas of processing, completing all transactions timely and accurately.
• Take accountability for the entire process from receipt of work to resolution.
• The ability to jump in and help. This is a “roll up your sleeves” position, and you will need to understand our business, our client’s business, and processes so you can help others effectively do their jobs.
• Work under general supervision following established procedures.

Senior Member Advocate supporting clients with Health Spending Account inquiries

Senior Member Services Advocate

Senior Member Advocate providing support for Health Spending Account inquiries via phone. Fostering relationships with clients through responsive service and assistance in enrollment processes.

• Remain available throughout agreed hours of coverage for contact by the RMI GCC.
• Deploy to pre-defined medical facilities in area of operation to meet and greet RMI patient within 1 hour of notification from GCC (Or any other agreed timeframes).
• Work in conjunction with the GCC to ensure that payment methods have been agreed with the receiving medical facility.
• Where applicable, act as a mediator between medical facility and GCC.
• Ensure swift access to care for RMI patients, responding to problems in a pragmatic and professional manner to resolve as quickly as possible.
• Provide translation from local dialect to English in both verbal and written forms and pass this on to the GCC.
• Deploy to medical facilities daily when a protracted in-patient stay occurs.
• Manage the welfare of patients through any admission to a medical facility, ensuring that the patient is comfortable, understands the treatment being provided and meet reasonable requests for support.
• Establish working relationships with treating physicians and where applicable speak directly with the treating medical team to acquire up to date information.
• Provide timely updates to the GCC on the status and proposed plans for the patient in both written and verbal forms.
• Always demonstrate a professional and calm persona, with a confident ability to liaise with client management as required.
• Utilize local knowledge to arrange other services, as required

Patient Advocate providing medical support and coordination for RMI

Patient Advocate

Patient Advocate providing medical support and coordination for Remote Medical Inc. Managing patient welfare and communication between medical facilities and RMI team.

• Build the initial claimant relationship and confidence in our firm with every prospective claimant interaction
• Engage in 150 – 200 calls per day in a professional inbound/outbound call center environment
• Consistently build the claimant relationship and confidence in our partners firms with every claimant interaction while proactively contacting claimants to ensure the relationship is maintained
• Solve problems and maintain confidentiality
• Keep updated records and detailed documentation of claimant interactions, concerns, and complaints in a paperless database system
• Use good judgment to discern what issues may be urgent and need a manager’s or director’s attention immediately
• Be expected to meet occupancy and adherence goals

Intake Advocate connecting claimants to legal assistance at Tort Experts

Intake Advocate

Intake Advocate assisting potential claimants with injury claims and guiding them through eligibility processes. Engaging in high call volumes to maintain claimant relationships and confidence in legal representation.

• Collaboration with the Member Advocate
• Receive balance-bill cases from the Member Advocate following intake, eligibility verification, and pathway determination; review the case file for completeness before initiating negotiation
• Coordinate with the assigned Member Advocate on member context, prior provider communications, and any sensitivities that should shape negotiation tone or approach
• Provide settlement updates and projected closure timeline to the Member Advocate on a defined cadence so the Advocate can keep the member informed within SLA windows
• Hand back to the Member Advocate at settlement for member confirmation, CSAT capture, and case closure in the case management system
• Research Medicare, market benchmarks, and applicable fee schedules to develop negotiation strategy and opening offers for each case
• Review provider claims for CPT/ICD coding accuracy, and billing reasonableness prior to negotiation; flag suspected coding errors or upcoding for Paralegal review when warranted
• Prepare a documented negotiation plan for each case identifying opening offer, target range, walk-away threshold, and supporting evidence
• Conduct direct payment negotiations with the provider or facility that issued the balance bill to the member, on the member’s behalf
• Manage the full negotiation lifecycle: provider outreach, counter-offer cycles, settlement execution, and case closure
• Operate within Negotiator-defined settlement authority thresholds; obtain Advocacy Team Manager authorization for settlement parameters that exceed those thresholds
• Where the case has been routed through delegation, partner with the delegated team or assume internal handling per the established hand-off criteria; ensure no duplicative provider outreach
• Document all negotiation activity, communications, and settlement terms in the case management system in real time and to audit-ready standards
• Maintain accurate, current case status so that the Member Advocate, Manager, and any delegated vendor can rely on a single source of truth for the case
• Collaborate with paralegals on legal case file preparation for complex, high-dollar, or multi-party negotiations
• Escalate unresolvable cases to the Advocacy Team Manager and coordinate transition to alternative dispute resolution, third-party arbitration, or external legal counsel as authorized
• Coordinate with Claims, Network Management, or Provider Relations when a negotiation reveals a contracting, configuration, or claim-processing issue requiring upstream correction
• Identify recurring provider billing patterns and report systemic issues to the Advocacy Team Manager for network-level correction
• Maintain current knowledge of applicable state balance billing law and the organization’s sharing program guidelines as they affect provider negotiation strategy
• Contribute lessons learned and successful negotiation tactics back to the team’s playbook and training materials
• Contribute to the exercise and expression of Christian Care Ministry’s Christian beliefs
• All other duties as assigned

Member Advocate Negotiator resolving balance bills at Christian Care Ministry

Member Advocate – Negotiator

Member Advocate Negotiator resolving balance bills for members at Christian Care Ministry. Engaging with providers and negotiating payments based on healthcare guidelines and member advocacy.

• The Member Advocate Negotiator works in close partnership with the Member Bill Advocate to resolve balance bills by engaging and negotiating directly with the provider or facility that issued the bill to the member.
• The Negotiator applies knowledge of Medicare reimbursement rates, market benchmarks, payer-provider fee schedules to anchor and advance negotiations toward a settlement that protects the member from unexpected out-of-network charges.
• The role owns the full negotiation lifecycle from case assignment through settlement execution and case closure.
• At lower activation scenarios, the Negotiator’s significant spare capacity supports provider contracting and network analytics.
• Hand back to the Member Advocate at settlement for member confirmation, CSAT capture, and case closure in the case management system.

Member Advocate Negotiator resolving balance bills for Christian Care Ministry

Member Advocate Negotiator collaborating with Member Bill Advocate to resolve balance bills for Christian Care Ministry. Engaging negotiation on behalf of members with healthcare providers.

Advocate jobs in Florida

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Service Advocate V – Appeals, Disputes

Senior Member Services Advocate

Patient Advocate

Intake Advocate

Member Advocate – Negotiator

Member Advocate – Negotiator