Summary
 

Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions.

Description
 

 
Job Description

Logistics:

PGBA – is a subsidiary company of BlueCross BlueShield of South Carolina.

Location:

This position is full time (40 hours/week) Monday-Friday in a typical office environment. Employees are required to have flexibility work any our 8-hour shift scheduled during hours of 10:00 AM –7:00 PM. Training will be Monday – Friday 8:00 AM - 4:30/5:00 PM for approximately 6-8 weeks. 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:

• Researches and responds to telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
• Research and respond to written inquiries and identify incorrectly processed claims and completes the adjustment and/or reprocessing action according to department guidelines. This may include initiating, documenting, and processing the request to completion. Initiate recoupments as necessary.
• Identifies complaints and inquiries of a complexity level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.
• Completes projects and/or assignments related to claims processing and customer service functions in the department.

To Qualify for This Position, You’ll Need the Following:

• Required Education:
• High School Diploma or equivalent
• Required Work Experience:
• 2 years of customer service experience OR 1 year of claims or appeals processing experience and 1 year of customer service experience OR Bachelor's Degree in lieu of work experience.
• Required Skills and Abilities:
•  Good verbal and written communication skills.
• Strong customer service skills.
• Good spelling, punctuation and grammar skills.
• Basic business math proficiency.
• Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools:
• Microsoft office

We Prefer That You Have the Following:

• Associate degree
• 3 years of customer service experience OR 2 years of customer service experience and 1 year of claims processing experience

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the fir