Claims Customer Service Advocate II

PGBA,•Columbia, SC

1d•Onsite

About The Position

The Claims Customer Service Advocate II reviews and adjudicates complex or specialty claims, deciding whether claims should be returned, denied, or paid in accordance with organizational policies, procedures, business and contract regulations, internal standards, and examining guidelines. The role also responds to routine correspondence and telephone inquiries about claims or appeals, identifies incorrectly processed claims, and performs adjustments and related reprocessing actions. The position is full-time, 40 hours per week, Monday through Friday, onsite at 17 Technology Circle in Columbia, South Carolina. Employees must be flexible to work any scheduled eight-hour shift between 9:00 a.m. and 6:00 p.m.; these hours will not change due to contractual obligations. Initial training is onsite at the GPC location, Monday through Friday, from 8:00 a.m. to 4:30 or 5:00 p.m. for approximately six to eight weeks. The position requires the ability to obtain a security clearance, and applicants must be U.S. citizens. The position is not eligible for current or future sponsorship. As an employee subject to the Service Contract Act, the employee is required to enroll in the company’s health insurance. Coverage begins on the first day of the month following 28 days of full-time employment; supplemental pay for health coverage is provided until enrollment is complete.

Requirements

High school diploma or equivalent.
Two years of experience processing, researching, and adjudicating claims.
Strong organizational, analytical, and judgment skills.
Strong oral and written communication skills.
Proficiency in spelling, punctuation, and grammar.
Proficiency in basic business math.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office skills.
Ability to obtain a security clearance; applicants must be U.S. citizens.

Nice To Haves

Two years of claims processing experience.
Tricare claims experience.
Strong time management skills.
Knowledge of mathematical and statistical concepts.
Proficiency in word processing and spreadsheet applications.
Proficient database software skills.

Responsibilities

Examine and process complex or specialty claims according to business and contract regulations, internal standards, and examining guidelines.
Enter claims into the claim system after verifying correct procedure and diagnosis coding, and verify that claims were keyed correctly.
Determine whether claims should be returned, denied, or paid in accordance with organizational policies and procedures.
Ensure claims are processed according to established quality and production standards.
Correct processing errors by reprocessing, adjusting, and/or recouping claims.
Research and resolve claims edits and deferrals, using policies, procedures, reference materials, and forms, and coordinating with internal support areas as needed.
Respond to routine correspondence and telephone inquiries about claims or appeals, and complete spreadsheets when applicable.
Assist in training or mentoring new staff members.