Claims Advocate II - Resolution & Reprocessing Pro

Pgba, Llc; Florence (SC); Hybrid; USD 36,000 - 48,000; Full time

Benefits offered by this job

Health plans

401K with company match

Life Insurance

PTO

On-site cafeterias/fitness centers

Wellness program

Tuition assistance

Employee Assistance

Discounts

Job summary

PGBA, LLC is seeking a full-time Claims/Appeals Processor in Florence, SC. The role requires handling inquiries, adjusting processing errors, and reprocessing claims in accordance with contract guidelines.

The position operates 9AM–6PM with 8-hour shifts, on-site at 200 N. Dozier Blvd., Florence, SC. U.S. citizenship and ability to obtain security clearance are required. Training is 6–8 weeks, Monday–Friday, 8:00 AM–5:00 PM.

Qualifications

• Required Education: A High School Diploma or equivalent.
• Required Work Experience: 1-year of experience including 1-year 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 Manage Confidential or Sensitive Information with Discretion.
• Required Software and Tools: Microsoft Office.
• We Prefer that you Have the Following: Associate degree (2) years-of claims processing or call center experience; Knowledge of word processing, spreadsheet, and database software.

Responsibilities

• 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.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensures claims are processing 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.

Skills

Verbal and Written Communication

Customer Service

Spelling and Grammar

Business Math

Confidential Information Handling

Education

High School Diploma or equivalent

Tools

Microsoft Office

Job description

PGBA, LLC is seeking a full-time Claims/Appeals Processor in Florence, SC. The role requires handling inquiries, adjusting processing errors, and reprocessing claims in accordance with contract guidelines.

The position operates 9AM–6PM with 8-hour shifts, on-site at 200 N. Dozier Blvd., Florence, SC. U.S. citizenship and ability to obtain security clearance are required. Training is 6–8 weeks, Monday–Friday, 8:00 AM–5:00 PM.