Processor, Claims II

PGBA,•Columbia, SC

1d•Onsite

About The Position

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members. Description Logistics: PGBA– one of BlueCross BlueShield's South Carolina subsidiary companies Location: This position is full-time (40 hours/week) Monday-Friday from 10:00am-7:00pm. This role is located on-site at 17 Technology Circle, Columbia SC Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. What You’ll Do: Examines and processes complex or specialty claims 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. Verifies that claims have been keyed correctly. Ensures that claims are processing according to established quality and production standards. Corrects processing errors by reprocessing, adjusting, and/or recouping claims. Research and resolves claims edits and deferrals. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas. Responds to routine correspondence and completes spreadsheet if applicable.

Requirements

High School Diploma or equivalent
2 years of experience processing, researching and adjudicating claims.
Strong organizational, analytical and judgment skills.
Strong oral and written communication skills.
Proficient in spelling, punctuation and grammar.
Proficient in basic business math.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office.
This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Nice To Haves

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

Responsibilities

Examines and processes complex or specialty claims 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.
Verifies that claims have been keyed correctly.
Ensures that claims are processing according to established quality and production standards.
Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
Research and resolves claims edits and deferrals.
Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas.
Responds to routine correspondence and completes spreadsheet if applicable.