FCMB Claims Customer Service Advocate II

PGBA,•Columbia, SC

17h•Onsite

About The Position

This full-time position is responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. The role involves identifying incorrectly processed claims and completing adjustments and related reprocessing actions. It is an on-site position located at 17 Technology Circle, Columbia SC, requiring flexibility to work any 8-hour shift scheduled between 10 AM and 7 PM, Monday through Friday. Training will be conducted Monday through Friday from 8:00 AM to 5:00 PM for approximately 6-8 weeks. Applicants must be U.S. Citizens to obtain a security clearance. The position is subject to the Service Contract Act (SCA), requiring employees to enroll in health insurance benefits, with supplemental pay provided until enrollment 28 days after the hire date. PGBA, LLC, a subsidiary of BlueCross BlueShield of South Carolina, provides administrative services for TRICARE and Veteran’s Health Administration programs.

Requirements

A High School Diploma or equivalent
1-year of experience including 1-year claims/appeals processing, customer service, or other related support area 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 Proficiency.
Ability to Manage Confidential or Sensitive Information with Discretion.
Microsoft Office.
Ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Nice To Haves

Associate degree
(2) years-of claims processing or call center experience.
Knowledge of word processing, spreadsheet, and database software.

Responsibilities

Responds to written and/or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
Accurately documents inquiries.
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
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.
Ensures claims are processing according to established quality and production standards.
Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.