Claims Customer Service Advocate II

PGBA•Columbia, SC

2d•Onsite

About The Position

The Claims Customer Service Advocate II responds to routine written correspondence and telephone inquiries regarding claims or appeals. The role identifies incorrectly processed claims and completes adjustments and reprocessing actions. It also examines and processes claims and non-medical appeals in accordance with business and contract regulations, internal standards, and examining guidelines. This is a full-time, on-site position with PGBA, a subsidiary of BlueCross BlueShield of South Carolina, at 17 Technology Circle in Columbia, South Carolina. The schedule is Monday through Friday, 40 hours per week, with an eight-hour shift during normal business hours of 8:00 AM to 6:00 PM. Occasional overtime may be necessary, and travel between buildings may be required. Initial training is on-site, Monday through Friday from 8:00 AM to 5:00 PM, for approximately six to eight weeks. The position requires the ability to obtain a security clearance, which requires U.S. citizenship. It 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 health 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 be used in lieu of 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.
Proficiency with Microsoft Office.
Ability to obtain a security clearance; applicants must be U.S. citizens.

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 while meeting 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 in accordance with 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 using desk procedures and guidelines to a lead or manager.
Identify and promptly report or refer suspected fraudulent activities and system errors to the appropriate departments.