FCMB Claims Customer Service Advocate II

001 BlueCross and BlueShield of South Carolina; Myrtle Beach (SC); On-site; USD 36,000 - 54,000; Full time

Job summary

PGBA, LLC, a leading administrator of TRICARE and health benefit programs, seeks a Claims Processing/Customer Service professional in the Myrtle Beach area to respond to routine inquiries by phone, identify misprocessed claims, and complete adjustments and reprocessing actions.

The role emphasizes accuracy, discretion with confidential information, and strong written and verbal communication, with opportunities to contribute to process improvements within a supportive, federal contractor

Qualifications

• Clear verbal and written communication skills.
• Strong customer service skills.
• Excellent spelling, punctuation and grammar.
• Basic business math proficiency.
• Ability to handle confidential or sensitive information with discretion.

Responsibilities

• Researches and responds to telephone inquiries according to desk procedures, ensuring timeliness, productivity and quality.
• Researches and responds to written inquiries and identifies misprocessed claims, completing adjustments and/or reprocessing actions; initiates recoupments as needed.
• Identifies complex complaints and inquiries and refers them to a lead or manager for resolution; reports potential fraud and abuse.
• Completes projects and assignments related to claims processing and customer service.

Skills

Verbal communication

Written communication

Customer service

Spelling/grammar

Business math

Confidentiality

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

Summary

Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions.

Description

• 60% Researches and responds to telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
• 20% Research and respond to written inquiries and identify incorrectly processed claims and completes the adjustment and/or reprocessing action according to department guidelines. This may include initiating, documenting, and processing the request to completion. Initiate recoupments as necessary.
• 10% Identifies complaints and inquiries of a complexity level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.
• 10% Completes projects and/or assignments related to claims processing and customer service functions in the department.

Required Work Experience

Two years of customer service experience OR one year of claims or appeals processing experience and one year of customer service 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 proficiency.
• Ability to handle confidential or sensitive information with discretion.

Required Software and Other Tools

Microsoft Office.

Work Environment

Typical office environment.

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.

Company Information

PGBA, LLC is a leading provider of administrative services for the TRICARE health benefit program and health benefit programs of Veteran’s Health Administration for both state and federal governments. The company has offices in Florence, Surfside Beach, and Columbia, South Carolina. PGBA employees work in an atmosphere that is conducive to growth and on that fosters a focus on personal and professional development with an environment made up of people from different parts of the world with diverse cultural Excellent benefits, as well as a competitive compensation program, make us one of the leading employers in today’s corporate market.