Summary
 

Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures.

Description
 

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 8:00 AM –5:00 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 are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

What You’ll Do:

• 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. Ensure claims are processed 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.

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

• Required Education:
• High School Diploma or equivalent
• Required Work Experience:
• 1 year of experience in claims/appeals processing, customer service, or other related support area 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

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits for the first of the month following 28 days of employment.  

• Subsidized health plans, dental and vision coverage
• 401K retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

Sponsorship: This position is not eligible for sponsorship now or in the future.

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What to Expect Next:

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