BlueCross BlueShield of South Carolina

Auditor

• Part-time (20-hours/week) remote Lead Auditor role coordinating and completing audit reviews
• Plan and execute audits per professional auditing standards; focus on operational controls, asset safeguarding, compliance
• Serve as in-charge auditor on complex audits and cost reports; review account reconciliations
• Prepare written work papers and reports; communicate audit status and results to management
• Assess desk reviews by subordinate auditors; mentor, coach, and direct day-to-day efforts of assigned audit staff
• Ensure audits comply with GAAP, GAAS, and Government Auditing Standards and meet budget/performance goals
• Assist in development/revision of work instructions, forms, procedures; maintain knowledge of applicable laws and regulations
• Some travel between office buildings; out of town travel may be required

Lead Auditor

Software Engineer

• Position Purpose: Responsible for analysis, design, programming, and implementation of the most complex applications tasks and projects
• Devise feasible, logical procedures to resolve business problems through the use of computer resources
• Formulate scope and objectives through research to develop or modify complex systems
• Provide technical direction and support in the development and support of business systems software and procedures
• Design, code, test and debug the most complex application programs
• Review and analyze systems, streamlining processes to ensure efficient, consistent use of all resources
• Provide technology solutions and prototypes as basis/templates for complex requirements
• Research, diagnose, and develop fixes for defects in existing code and address maintenance issues
• Act as an internal consultant, advocate, mentor, and change agent providing expertise and technical guidance
• Work closely with customers, business analysts, and team members to determine business requirements and ensure alignment with IT strategies
• Provide design recommendations, participate in component and data architecture design, performance monitoring, and product evaluation
• Involved in full systems life cycle: designing, coding, testing, implementing, maintaining and supporting application software
• Lead, plan, organize, and/or coordinate complex projects or phases and provide guidance to lower-level programmers/analysts

Senior BigFix Developer

Medical Reviewer

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Provides support and review of medical claims and utilization practices.
• Location: Palmetto GBA – one of BlueCross BlueShield’s South Carolina subsidiary companies.
• Location and training: Six week paid training class with one week of onsite training and five weeks of remote training. One week of onsite training in Columbia, SC, or Birmingham, AL. Training classes start on 06/23/25 and 07/21/25. No time off during training.
• What You'll Do: Perform medical claim reviews for medically complex services and preauthorization/predetermination; determine medical necessity and payment determinations; monitor timeliness; document medical rationale; educate staff; participate in quality control; mentoring; assist with special projects and specialty duties and responsibilities as assigned by management.

RN Medical Reviewer II

Medical Director

• 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.
• May develop and update 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.

Chief Medical Officer - Medicare DME

Compliance

• Drafts and revises contract filings to initiate formal approval process within the division
• Ensures compliance of revisions with corporate and/or legal requirements
• May participate in negotiations with state regulators to ensure all parties agree on final contract documents
• Researches and interprets statues and regulations, and bulletins to answer applicable questions or issues regarding regulatory compliance
• Reviews legislative changes and assists in determining impact to division contracts
• Incorporates necessary revisions into the workplace by facilitating the implementation of regulatory requirements
• Coordinates resources to ensure all division materials are legally compliant with state and federal regulations
• May review department materials and/or plan program materials for compliance and quality
• Ensures all documents are properly placed on both internal and external websites in an accurate and timely manner
• Acts as liaison with compliance area, other divisions, and government agencies
• Ensures compliance with applicable contract provisions and government regulations
• May conduct internal and external compliance reviews and audits
• Identifies necessary improvements
• Investigates and resolves compliance issues

Regulatory Compliance Specialist

Customer Support

• Responds to customer inquiries via telephone, written, web, or walk-in inquiries
• Performs research as needed to resolve inquiries
• Reviews and adjudicates claims and/or non-medical appeals
• Determines whether to return, deny or pay claims following organizational policies and procedures
• Enters 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
• Identifies and reports potential fraud and abuse situations
• Location: On-site at 4101 Percival Road, Columbia SC; Full-time schedule with 8-hour shifts 8:00 AM–8:00 PM; Training 8:00 AM - 4:30 PM for ~6-8 weeks

Claims Customer Service Advocate II - Hybrid

• Conduct 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.
• Develop detailed reports on each audit conducted. Report includes 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.
• Conduct special audit studies for management, such as those required to discover controls for prevention of fraud.
• Prepare reports of finding and recommendations for management.
• Assist 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

Analyst

We are currently hiring for a RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as a RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
Location This position is full time (40 hours/week) Monday-Friday from 8:00am – 5:00pm and will be fully remote.
What You’ll Do: Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. Performs special projects including reviews of clinical information to identify quality of care issues.

RN Appeals Analyst, Remote

Operations

• Under general supervision, analyzes proposed policies, procedures, forms, and reports; Recommends operational improvement through standardization, simplification, discontinuance and other methods; Recommends installations of new systems/procedures; Reviews organizational functions and structure to avoid overlapping or duplication; May provide security administration to application supported by area when the appropriate written and approved request is received.
• Location: This role is remote, full time M-F 8am-5pm
• Evaluates existing procedures and processes to make recommendations for improvement
• Monitors reports to assess the impact of performance on key measures
• Provides reports and/or analyses of internal performance metric for various projects as well as for individual performance against those metrics
• Assists in the implementation and maintenance of systems or processes to include testing
• May manage and relay the purpose, scope, and status of each implementation to management
• Develops and maintains written procedures within departmental and organizational standards
• May document and streamline automated procedures into end-user training material
• Conducts workflow and process audits of staff and reference materials as needed
• Works with staff and manager to research and document errors, progress, performance or other metrics to assess efficiency
• Provides training for new employees and ongoing training as workflow efficiencies are revised
• Generates data to prepare reports and maintain databases and/or requests reports on specific statistics in order to analyze trends
• Maintains area reports
• Quality check records affecting accuracy of reports by researching and testing processes and methods
• Maintains close contact with management to provide updates on any issue/projects
• Completes special projects and informs management of any trends or changes in statistical reports
• May serve as liaison between the department and other internal/external groups