Claims Customer Service Advocate III

Pgba, Llc; Columbia (SC); On-site; USD 52,000 - 76,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings with company m

Life Insurance

Paid Time Off

On-site cafeterias and fitness centers

Education Assistance

Job summary

BlueCross BlueShield of South Carolina is seeking a Claims Customer Service Advocate III in Columbia. You will provide prompt, accurate responses to complex inquiries, review and adjudicate claims and non-medical appeals, and research issues to determine appropriate outcomes based on policy requirements.

This on-site role requires 3 years of customer service with claims/appeals processing or a Bachelor's degree in lieu of experience, plus a High School Diploma.

Qualifications

• 3 years of customer service experience, including 1 year of claims or appeals processing, or a Bachelor's degree in lieu of experience.
• High School Diploma required.
• Strong verbal and written communication; ability to handle confidential information with discretion.

Responsibilities

• Review claims or appeals and determine if procedures were followed.
• Research underlying causes and recommend corrective actions.
• Identify potential fraud/abuse and report it.
• Enter claims into the system with proper coding and accuracy.
• Ensure processing meets quality and production standards.
• Provide feedback to management and assist with process improvements.
• Assist in training customer service representatives.

Skills

Communication skills

Customer service

Confidentiality

Business math

Microsoft Office

Education

High School Diploma

Bachelor's Degree (in lieu of experience)

Tools

Microsoft Office

Job description

## Claims Customer Service Advocate IIIApply: On-site: Columbia, South Carolina: Full time: Posted Yesterday: End Date: November 14, 2026 (2 days left to apply): R1053129# **Summary**Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries. Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates complex or specialty claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures.# **Description**Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! **Position Purpose**:Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries. Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates complex or specialty claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures.**Logistics:** PGBA **–** one of BlueCross BlueShield's South Carolina subsidiary companies. **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 9AM –6PM. Training will be Monday – Friday 8:00 AM - 4:30/5:00pm on site at the GPC Location. for approximately 6-8 weeks. This role is located on site at 17 Technology Circle, Columbia SC. Hours will not change due to contractual obligations. * **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*)*.* **As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.** **Sponsorship**: This position is not eligible for sponsorship now or in the future. **What You Will Do:*** Review claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed. Research to identify underlying causes, and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.* Research and respond to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met. Handles situations that require adaptation of response or extensive research.* 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.* Provide feedback to management regarding customer issues. Maintain accurate records concerning issues. Follow through on complaints until resolved or report to management as needed.* Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies. Assists in training claims customer service representatives **To Qualify for This Position, You Will Need:*** **Required Work Experience:** 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.* **Required Education:**High School Diploma or equivalent* **Required Skills and Abilities:**Good verbal and written communication skills. Strong customer service skills. Good spelling, punctuation, and grammar skills. Basic business math abilities. Ability to handle confidential or sensitive information with discretion.* **Required Software and Other 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 the first of the month following 28 days of employment. * Subsidized health plans, dental and vi* sion coverage* 401k retirement savings plan with company match* Life Insurance* Paid Time Off (PTO)* On-site cafeterias and fitness centers in major locations* Education Assistance* Service Recognition* National discounts to movies, theaters, zoos, theme parks and more **What We can Do for You:**We 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:**After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.**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 [e-mail] or call 800-288-2227, ext. 47480 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. Here's more information.Some states have required notifications. Here's more information.