BlueCross BlueShield of South Carolina

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 – Cost Reporting

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 and 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/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.

RN Medical Reviewer II

Medical Director

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on issues concerning medical policies
• Writes and revises medical policies
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

Medicare Medical Director

• Perform 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, and correct coding for claims/operations
• Make reasonable 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
• Monitor process’s timeliness in accordance with contractor standards
• Document medical rationale to justify payment or denial of services and/or supplies
• Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participate in quality control activities supporting 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 and responsibilities as assigned by management

RN Medical Reviewer II – RCD Medicare

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policies
• May write and revise medical policies
• Develops claim adjudication criteria
• Provides input on operational policies, processes, and procedures
• Educates staff and medical community on medical policy and program administration
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and other statistical data
• Conducts research into new or controversial medical procedures and technology

Molecular Diagnostics Medical Director

• 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

• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Provides support and review of medical claims and utilization practices.
• Monitors process's timeliness in accordance with contractor standards.
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Performs screenings/assessments and determines risk via telephone.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives.

LPN Medical Reviewer

• Independently and objectively plans and executes audits
• Performs or supports audits focused on operational controls
• Functions as in-charge auditor of complex audit reviews
• Identifies and analyzes key processes, systems, and controls
• Communicates audit status and results to management
• Prepares formal written work papers and reports
• Assesses desk reviews performed by subordinate auditors
• Coordinates completion of assignments

Part-Time Lead Medicare Cost Reporting Auditor

Claims Specialist

• Reviews and adjudicates complex or specialty claims
• Determines whether to return, deny or pay claims following organizational policies and procedures
• Assists in training or mentoring new staff members
• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes
• Verifies that claims have been keyed correctly
• Ensures that claims are processing according to established quality and production standards
• Corrects processing errors by reprocessing, adjusting, and/or recouping claims
• Researches and resolves claims edits and deferrals
• Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas
• Responds to routine correspondence and completes spreadsheet if applicable

Claims Processor II

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls
• Identifies, documents, and evaluates business risks
• Documents issues, the causes of those issues, and their effects on the process/function and the corporation
• Drafts recommendations to limit risks and improve processes, functions and activities
• Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies
• Conducts testing of corrective actions as identified
• 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
• Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud
• Prepares reports of findings 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

Medicare Cost Reporting Auditor II

• Performs medical claim reviews and makes a reasonable charge payment determination
• Monitors process's timeliness in accordance with contractor standards
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Utilizes allocated resources to back up review determination
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process
• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
• Performs screenings/assessments and determines risk via telephone
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services
• Provides education to members and their families/caregivers
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each
• Conducts research necessary to make thorough/accurate basis for each determination made
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations
• Participates in quality control activities in support of the corporate and team-based objectives
• Participates in all Required Licenses and Certificates

LPN Medical Reviewer I-2

Analyst

• Research the substance of complex appeal or retrospective review requests
• Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines
• Document decisions within mandated timeframes and in compliance with applicable regulations or standards
• Performs thorough research of the substance of service appeals by both member and provider
• Adhere to confidentiality regulations regarding protected health information
• Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information
• Perform special projects including reviews of clinical information to identify quality of care issues

RN Appeals Analyst

Account Executive

• Provides day-to-day service and support to groups/agents/account representatives.
• Gathers needed information from client/agent to complete marketing package.
• Identifies and resolves issues/problems within assigned region.
• Develops marketing plans for both new sales and existing accounts.
• May lead internal execution of renewals, changes and new group transitions.
• Resolves escalated questions, problems or issues that arise.
• Prepares client marketing materials.
• May coordinate and conduct training sessions, enrollment meetings, and site visits.
• Trains group leaders/agents/account representatives/members on appropriate BCBSSC policies, procedures, and processes.
• Assists in training of new service representatives/office staff regarding implementation of new accounts/retention paperwork/new products and services.
• Assists director/manager with special projects to include presentations to potential prospects/existing accounts.
• Prepares weekly/monthly/annual activity reports for management.

Stop Loss Account Executive

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policies
• Writes and revises medical policies as needed
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria requiring medical judgment
• Provides input on operational policies, processes, and procedures
• Educates staff and the medical community on medical policy and program administration
• Develops and updates medical policy in consultation with various stakeholders
• Develops external relationships with the medical community and serves as liaison

Physical Medicine and Rehabilitation Medical Director

• Responsible for establishing the Companion Life brand within the assigned sales territory.
• Driving sales associated with Employee Benefit portfolio marketed through our organization.
• Generate new premium and maintain persistency of the enforce block of business.
• Communicates effectively with Partner Plans, consultants and client accounts, managing mutual goals, objectives and expectations.
• Assesses and implements resources for effective account management and the training of partner plan account management and sales staff.
• Establishes and maintains a highly visible presence with Partner Plan Account Management to ensure success.
• Uses independent judgment to regularly and responsibly direct the day-to-day activities of staff.
• Assigns work according to skillset and availability of staff to ensure departmental goals are achieved on a timely basis.
• Actively participates in the selection of candidates. Addresses performance issues, taking appropriate disciplinary action up to and including termination of employment.
• Monitors the marketplace regularly to identify trends in sales, competition, BlueCross BlueShield Association initiatives and product design.
• Sends/shares data to senior management, partner plans and client accounts for review on a regular basis.
• Establishes and maintains positive partner plan/client account distribution channel relations.
• Manages working relationship with partner plans and client accounts including legal, policies and procedures, and issue resolution.
• Monitors performance metrics and distributes to account management.
• Coordinates ongoing partner plan and client account meetings including but not limited to Executive Oversight or Steering Committee meetings, quarterly and/or semiannual account management oversight, etc.