BlueCross BlueShield of South Carolina

Customer Support

• Ensure effective customer relations by responding accurately, timely, and courteously to inquiries
• Handle non-routine inquiries which may require adaptation of response or extensive research
• Identify incorrectly processed claims and processes adjustments according to department guidelines
• Examine and process claims and/or non-medical appeals according to business/contract regulations
• Enter claims into the claim system after verification of correct coding
• Ensure claims are processing according to established quality and production standards
• Identify and report potential fraud and abuse situations

Claims Customer Service Advocate II

Medical Reviewer

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement
• Monitors process’s timeliness in accordance with contractor standards
• Documents medical rationale to justify payment or denial of services and/or supplies
• Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines
• Participates in quality control activities in support of the corporate and team-based objectives
• Provides guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assists with special projects and specialty duties/responsibilities as assigned by management

Medical Reviewer II – Prior-Auth A/B MAC

Manager

• Responsible for the management of assigned claims operation(s)
• Ensure investigation and adjudication of claims meet performance standards and objectives
• Develop and maintain effective working relationships with business partners
• Responsible for the development of claims staff, vendors, and contractors
• Complete requests for proposal, bids, and due diligence on potential new jurisdictions
• Assist claims senior management team in achieving departmental and corporate strategies and goals

Manager, P & C Claims – Workers Compensation, General Liability

Administration

• Provides supervision and direction of the statistical reporting function and data analysis
• Monitors adherence to statistical reporting requirements
• Updates systems as necessary
• Sets and maintains general direction/focus of statistical reporting function
• Perform analysis and reporting including performing clinical trend analysis
• Develop reports through various data reporting tools
• Develop data driven solutions to improve outcomes
• Collaborate with other areas to reduce expense through data analysis
• Serve as internal subject matter expert and point of contact for query/design for clinical analysis
• Identifies data analysis needs based on customer
• Supervises staff including directing work, addressing performance, and providing training
• Review work and coaches subordinates

Clinical Reporting Supervisor

Auditor

• Conducts audits of the financial, management, and administrative procedures of assigned divisions, providers, departments, and various lines of businesses throughout the organization to ensure that procedures are in compliance.
• Audits include interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices to determine effectiveness, and reviewing relevant documentation to support findings.
• Develops detailed reports on each audit conducted.
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes.
• Conducts testing of corrective actions as identified.
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud.
• Prepares reports of finding and recommendations for management.
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel.

Auditor I, Medicare

Account Executive

• Develops and executes marketing plans for new sales and/or retention of existing accounts within assigned territory.
• Prepares and presents proposals and communications to groups, agents, and/or individuals.
• Develops and maintains professional relationships with groups, agents, and/or individuals.
• Assesses agency, agent, and/or individual sales opportunities and works with groups, agents, and/or individuals to resolve problem issues.
• Conducts on-going market research and provides key information that may lead to sales.
• Prepares and submits required marketing reports to management detailing how best to position company products.
• Maintains product/industry knowledge and marketing skills by attending trading seminars, continuing education classes, conferences, etc.

Sales Representative II

Account Manager

• Serves as the internal day-to-day client account manager
• Works with Consultants, Client Advocates, NA Operations and Support, Reporting Medical Management, Product Development, etc.
• Participates in the implementation of new clients
• Assists in the assessment of client-specific benefits to determine set up in the Group Library
• Monitors key deliverable dates related to marketing
• Trains clients and consultants on E bill
• Handles escalated or system problems identified by the Account Advocates
• Assures quality including accuracy of SBCs, Benefit Booklets and other client/member facing materials

Client Relationship Manager II

Consultant

• Assess for needs related to a member’s chronic condition, clinical risk and readiness for change via company needs questionnaire
• Based on the needs assessment, complete and coordinate action plans in cooperation with members, then implement plans to include member goals
• Provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to elicit behavior change and increase member program engagement
• Participates in patient education with members and providers regarding the member’s condition and available benefit plans
• Serves as member advocate through continued communication and education
• Promotes enrollment in health and chronic condition management programs
• Provides appropriate communications (written, telephone) regarding member conditions to both health care providers and members
• Participates in data collection/input into system for clinical information flow
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal)
• Maintains current knowledge of network status of all service providers to educate members on care they may receive related to their chronic condition(s)
• Assists members with referrals to appropriate internal support areas to ensure proper processing of authorized or unauthorized services, as needed

Chronic Disease Coach, RN / Lactation Consultant

Sales

• Maintains market share of corporate by selling and renewing assigned accounts.
• Identifies/addresses issues/concerns within existing accounts.
• Monitors marketplace to identify trends in sales, competitors, or product design.
• Manages the coordination of issue resolution with customers/clients as it relates to implementation, renewals, and ongoing account management.
• Develops, implements, and manages marketing strategies and product lines for assigned region.
• Develops and implements short and long-range plans and budgets within assigned region.
• Assists sales as needed with presentations and hosting potential/current prospects/clients and potential/current accounts.
• May assist with the renewal of existing accounts and for ensuring appropriate operational tasks are completed for the implementation of new accounts.
• May assist in the sales of ancillary products.
• Manages the accurate communication of specific benefits for assigned accounts to operational areas including customer service, claims, benefit files, and membership.
• Coordinates with all operational departments on the administration of assigned accounts.
• Recruits, develops, trains, and guides/directs staff to meet, maintain, and increase the sales, retention, and service goals of BCBSSC products for assigned region.
• Develops and maintains excellent relationships with business partners, vendors, potential business partners, groups, agents, and brokers.

Director, Individual Sales

• Develops and executes marketing plans for new sales and/or retention of existing accounts within assigned territory.
• Prepares and presents proposals and communications to groups, agents, and/or individuals.
• Develops and maintains professional relationships with groups, agents, and/or individuals.
• Assesses agency, agent, group, and/or individual sales opportunities and works with groups, agent, and/or individuals to resolve problem issues.
• Conducts on-going market research and provides key information that may lead to sales.
• Prepares and submits required marketing reports to management detailing how best to position company products.
• Maintains product/industry knowledge and marketing skills by attending trading seminars, continuing education classes, conferences, etc.

Sales Representative

Actuary

• Maintains actuarial reporting systems, analyzes data, summarizes findings, and provides recommendations to support key actuarial functions
• Compiles monthly and quarterly actuarial reports
• Extracts complex data into spreadsheet form
• Performs profitability analysis and determination of appropriate level and rates for various lines of business
• Reviews state insurance department rate filings, making premium comparisons with competing companies
• Correctly prepares and documents rate filings and other submissions to state regulatory authorities
• Completes ad hoc reporting for financial and insurance data by state insurance departments
• Develops actuarial computer models and technically supports the actuarial staff
• Serves as a liaison to the information systems department
• Accurately determines reserves for reported and unreported liabilities
• Establishes the review of various methodologies used to promulgate these reserves
• Directs, motivates, and develops other Actuarial Team members

Associate Actuary

• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitor process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assist with special projects and specialty duties/responsibilities as assigned by management.

RN Medical Reviewer III

• Conducts internal and/or external timely operational, financial, and/or compliance audits
• Identifies, documents, and evaluates business risks
• Develops written audit programs
• Conducts testing and analysis of existing controls
• Prepares written work papers to document testing results and conclusions
• Serves as Lead Auditor on more complex audit assignments
• Drafts recommendations to limit risks and improve processes
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws
• Conducts testing of corrective actions
• Develops detailed reports on each audit conducted
• Conducts special audit studies for management
• Provides training to and assists or leads other auditors

Auditor III

• Independently and objectively helps plan and execute audits in accordance with professional auditing standards
• Performs or supports audits focused primarily on operational controls, asset safeguarding, and compliance with procedures, laws, and regulations
• Functions as in-charge auditor of the most complex audit reviews and/or cost reports
• May conduct reviews of account reconciliations performed by various financial areas
• Identifies and analyzes related key processes, systems, and controls to determine effectiveness
• Communicates audit status and results to management, with emphasis on discussing deficiencies and recommending corrective actions
• Prepares formal written work papers and reports, documenting audit work performed and expressing conclusion
• Assesses desk reviews performed by subordinate auditors to ensure that quality audit work is performed and on-the-job training is provided as necessary
• Assists in ensuring that all assigned audits are completed and reviewed in accordance with Generally Accepted Accounting Principles, Generally Accepted Auditing Standards and, Government Auditing Standards
• Coordinates the completion of these assignments in a manner which results in timely completion of all assignments in accordance with budget performance requirements as well as departmental interim goals
• Directs the day-to-day efforts of assigned audit staff by reviewing and planning assignments, training, and providing leadership and guidance
• Assists in the development and revision of work instructions, forms, and procedures
• Broadens and maintains working knowledge of applicable laws, regulations, and procedures through self-study programs, on-the-job training, attending seminars and network association’s formal training programs
• Communicates with internal and external areas as necessary to ensure efficient completion of assigned tasks

Lead Auditor, Medicare

Compliance

• Responsible for conducting investigations, preparing reports, work papers, and performing vulnerability assessments to recognize and identify potential compliance issues.
• Provides guidance to management and employees as needed.
• Conducts annual vulnerability risk assessment audits for division.
• Assists management in preparation and conduct of management control reviews.
• Performs detailed investigations of allegations/compliance issues and maintains tracking and quality databases.
• May develop, implement, and present ongoing training, and conduct periodic surveys and awareness initiatives.
• May be required to submit regulatory reporting data according to government schedule.