Advanced Claims Adjudication Specialist

Pgba, Llc; Columbia, Northern (SC, KY); Hybrid; USD 42,000 - 56,000; Full time

Benefits offered by this job

On-site cafeterias and fitness centers

Education Assistance

Paid Time Off (PTO)

Job summary

PGBA, a BlueCross BlueShield South Carolina subsidiary, is seeking a Claims Processor II to join our Columbia, SC office. This full-time, on-site role runs Monday–Friday, 8am–5pm, at 17 Technology Circle, Columbia, SC 29203. Sponsorship is not available for this position.

The ideal candidate will review and adjudicate complex claims, verify coding accuracy, and ensure compliance with internal standards while mentoring newer staff. Strong organizational and communication skills are essential.

Qualifications

• High School Diploma or equivalent.
• 2 years of experience processing, researching and adjudicating claims.
• Strong organizational, analytical and judgment skills.
• Proficient in spelling, punctuation and grammar; basic business math.

Responsibilities

• Examines and processes complex or specialty claims according to regulations and guidelines.
• Enters claims into the claim system after verification of coding.
• Verifies correct keying of procedures and diagnosis codes.
• Ensures processing according to established quality and production standards; corrects errors.
• Resolves claim edits and deferrals; researches problems using policies and forms; coordinates with internal support areas.
• Responds to routine correspondence and completes spreadsheets as applicable.

Skills

Organizational skills

Analytical skills

Judgment skills

Oral and written communication

Confidentiality

Business math

Education

High School Diploma or equivalent

Tools

Microsoft Office

Database software

Job description

PGBA, a BlueCross BlueShield South Carolina subsidiary, is seeking a Claims Processor II to join our Columbia, SC office. This full-time, on-site role runs Monday–Friday, 8am–5pm, at 17 Technology Circle, Columbia, SC 29203. Sponsorship is not available for this position.

The ideal candidate will review and adjudicate complex claims, verify coding accuracy, and ensure compliance with internal standards while mentoring newer staff. Strong organizational and communication skills are essential.