Claims Customer Service Advocate I

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 to 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 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, 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 Respond to written and telephone inquiries according to desk procedures, ensuring contract standards and objectives for timeliness, productivity, and quality are met. Accurately document inquiries. Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines. Examine and process claims and/or non‑medical appeals according to business/contract regulations, internal standards, and examining guidelines. Enter 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. Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution. Promptly report and/or refer 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 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. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case‑by‑case basis. We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. #J-18808-Ljbffr Dormont Manufacturing Co