Customer Service Advocate III

PGBA,•Columbia, SC

2d•Onsite

About The Position

This position provides prompt, accurate, thorough, and courteous responses to all complex customer inquiries. These inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. The role involves performing research as needed to resolve inquiries. This is a full-time (40-hours/week) Monday-Friday position in a typical office environment, with an 8-hour shift scheduled during normal business hours (8am-6pm). Occasional overtime may be necessary, and travel between buildings may be required. The role is located at 4101 Percival Road, Columbia SC. PGBA, LLC is a leading provider of administrative services for the TRICARE health benefit program and health benefit programs of Veteran’s Health Administration for both state and federal governments. The company has offices in Florence, Surfside Beach, and Columbia, South Carolina. PGBA employees work in an atmosphere that is conducive to growth and fosters personal and professional development within a diverse cultural environment.

Requirements

High School Diploma or equivalent
3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
Good verbal and written communication skills.
Strong customer service skills.
Good spelling, punctuation, and grammar skills.
Basic business math abilities.
Ability to handle confidential or sensitive information with discretion.

Nice To Haves

3 Years-Customer service or claims processing experience.
Associate degree-Any Major
Ability to persuade, negotiate or influence.
Knowledge of database software.
Cohere Experience, Genesys, and Bluesteps.

Responsibilities

Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
Research to identify cause and mine ways to prevent and correct such causes.
Identifies and reports potential fraud and abuse situations.
Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met.
Handles situations that require adaptation of response or extensive research.
Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
Ensure claims are processed according to established quality and production standards.
Provide feedback to management regarding customer issues.
Maintain accurate records concerning issues.
Follow through on complaints until resolved or report to management as needed.
Maintain knowledge of procedures and policies.
Assist with process improvements by recommending improvements in procedures and policies.
Assists in training claims customer service representatives.