Claims Customer Service Advocate II

PGBA•Columbia, SC

3d•Onsite

About The Position

The Claims Customer Service Advocate II responds to routine written correspondence and telephone inquiries about claims or appeals. The role identifies incorrectly processed claims and completes adjustments and related reprocessing actions. It also examines and processes claims and non-medical appeals under applicable business and contract regulations, internal standards, and examining guidelines. This is a full-time, onsite role with PGBA, a subsidiary of BlueCross BlueShield of South Carolina, at 17 Technology Circle in Columbia, South Carolina. The regular schedule is Monday through Friday, 40 hours per week, with flexibility to work an eight-hour shift scheduled between 9 a.m. and 6 p.m. Training is Monday through Friday, 8 a.m. to 5 p.m., for approximately six to eight weeks. Applicants must be U.S. citizens and able to obtain a security clearance. The position is not eligible for sponsorship now or in the future. Under Service Contract Act requirements, employees must enroll in health insurance benefits regardless of other coverage; supplemental pay is provided until enrollment in benefits 28 days after hire.

Requirements

High school diploma or equivalent.
One year of experience, including one year in claims or appeals processing, customer service, or another related support area; a bachelor's degree may substitute for work experience.
Good verbal and written communication skills.
Strong customer service skills.
Good spelling, punctuation, and grammar skills.
Basic business math proficiency.
Ability to manage confidential or sensitive information with discretion.
Microsoft Office proficiency.
Must be a U.S. citizen and able to obtain a security clearance.

Nice To Haves

Associate degree.
Two years of claims processing or call center experience.
Knowledge of word processing, spreadsheet, and database software.

Responsibilities

Respond to written and telephone inquiries according to desk procedures and meet contract standards for timeliness, productivity, and quality.
Accurately document inquiries.
Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
Examine and process claims and non-medical appeals according to business and contract regulations, internal standards, and examining guidelines.
Enter claims into the claim system after verifying correct procedure and diagnosis coding.
Ensure claims are processed according to established quality and production standards.
Refer complex complaints and inquiries that cannot be resolved under desk procedures and guidelines to a lead or manager.
Identify and promptly report or refer suspected fraud and system errors to the appropriate departments.

Benefits

Subsidized health plans, dental and vision coverage; benefits eligibility begins the first of the month following 28 days of employment.
401(k) 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 Program.
Discounts to movies, theaters, zoos, theme parks, and more.
Supplemental pay until enrollment in health benefits 28 days after hire, as described under Service Contract Act requirements.