BlueCross BlueShield of South Carolina

Administrative Assistant

• Provides daily professional administrative, clerical, and project coordination support
• Maintains area files, correspondence, reports, and other documentation
• Coordinates, completes, and delivers required reporting
• Types, edits, formats, reviews, and updates forms, correspondence and reports
• Maintains area files and binders
• Maintains area organizational charts, job descriptions, contact and mailing lists, desk procedures, and interoffice tracking logs
• Provides general clerical duties and administrative support including ordering supplies, coordinating meeting functions, arranging travel, maintaining calendars, and phone coverage for upper management
• Special projects as assigned

Senior Administrative Associate

Customer Support

• Provide prompt, accurate, thorough and courteous responses to all customer inquiries
• Perform research as needed to resolve inquiries
• Ensure effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk-in inquiries
• Accurately document inquiries
• Initiate or process adjustments or perform other research as needed to resolve inquiries
• Coordinate with other departments to resolve problems
• Respond to, research and/or assist with priority inquiries and special projects as required by management
• Provide feedback to management regarding customer problems, questions and needs
• Maintain accurate records on complaints and/or other customer comments and make recommendations for changes to management
• Follow through on complaints until resolved or report to management as needed
• Maintain basic knowledge of quality work instructions and company policies
• Assist with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations
• Maintain all departmental productivity, quality, and timeliness standards
• Identify and promptly report and/or refer suspected fraudulent activities and system errors to the appropriate departments

Customer Service Advocate

Administration

• Develops comprehensive reports and analyzes data in order to identify patterns and trends
• Assists in creating materials that aid in illustrating analytical/data findings
• Designs, codes, maintain and executes simple to complex database programs for the extraction and presentation of data for standard and ad hoc reporting
• Utilizes statistical programming tools to identify patterns and trends in data
• Assists in sampling design, sample selection, and relevant projections
• Performs statistical validations of sampling and related projections
• Assists with preparation of charts, illustrations, other graphics and narrative reports to explain findings
• Assists with development of complex statistical analysis, including standard reporting, AD HOC reporting, and data mining tools
• Assists with sophisticated data interpretation, compilation, and verification to guide departmental efforts
• Provides assistance in development of project plans and system life cycle maintenance, development of change requests and test plans impacting existing databases, and in the research of new sources for data
• Verifies data in existing databases and assists in the collection of data and management of existing databases
• Creates supporting documentation outlining procedures within scope of responsibility

Statistical Programming Analyst II

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, 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.

Strategic Sales Representative

Manager

• Provide care management services to more than 2 million members in South Carolina and nationally
• Administer complex, high-touch concierge case management for members identified into specialized programs such as high-risk maternity, NICU, ESRD, Cancer, Palliative Care or Behavioral Health
• Identify risks and provides outreach services to facilitate the coordination of healthcare services and gap closure
• Provide individualized care plans to ensure cost-effectiveness, overall care satisfaction, and improved quality of life
• Directs day-to-day, high-touch member management to include implementation of program goals, coordination of treatment plans and benefit coordination for high-risk patient populations and/or those with complex conditions
• Coordinates clinical services with external sources to include: providers, vendors, facilities, social workers/case managers and/or community services
• Participates in team training and continuing medical education
• Prepares for external audits and quality assurance efforts

RN Concierge Care Manager – Maternity, NICU

Care Coordinator

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
• Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans
• Serves as member advocate through continued communication and education
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members
• Ensures coverage for appropriate services within benefit and medical necessity guidelines
• Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.)
• Participates in data collection/input into system for clinical information flow and proper claims adjudication

Managed Care Coordinator II – Oncology Focus

Business Analyst

• Assists in formulating and defining systems scope and objectives using research and basic understanding of business systems and industry requirements.
• Learns to conduct business process analyses, needs assessments and cost/benefits analyses.
• Provides assistance in testing efforts and may provide security administration to application.
• Evaluates the activities, performance and systems within a specific area for standards and workflow simplification.
• Compiles data for analysis and prepares reports and presentations.
• Reviews system enhancements/upgrades to determine applicability of customer file modification requirements.
• Facilitates timely and accurate updates to reference files.
• Coordinates testing and debugging of new or modified software.
• Creates test matrices and supporting documentation.
• Develops and executes formal test plans to ensure delivery of quality software applications.
• Monitors software implementations for exceptions and to verify that changes had the desired effect.
• Identifies and documents systems problems and assists in their resolution.
• Researches system problems and identifies potential solutions.

Accounting Manager

• Identifies, investigates, and recovers incorrectly paid medical claims
• Analyzes payment data and verifies overpayments
• Documents findings and coordinates with providers for reimbursement according to Medicare guidelines
• Prepares various in-depth financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, and disputes
• Ensures data is complete, accurate, and organized for processing
• Provides summary reports of accounting activities
• Completes moderately difficult to complex research using financial reporting systems
• Resolves questions and problems, referring most complex issues to higher levels
• Performs calculations on financial documents to ensure accuracy
• Prepares journal entries and account reconciliations
• Responds to inquiries from internal and external customers

Accounting Technician III

Health Coordinator

• Perform primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy of assigned members.
• In person contact with the member is required.
• Collaborate and communicate with the member, member's family/caregiver and other healthcare professionals involved in the member’s care.
• Ensure care coordination and case management activities are aligned with members' risk levels and identified strengths, preferences, needs and desired outcomes.
• Assist with implementation of health management activities/programs for membership.
• Complete in-person assessments in the member’s residence or least restrictive environment.
• Monitor member compliance and success rate.
• Assist with development of strategies to increase effectiveness of and participation in health management programs.

Behavioral Health Intensive Care Management Coordinator

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

Entry Level Cost Auditor

Nurse Navigator

• Monitor/implement quality improvement/management activities
• Conduct specific medical reviews as necessary
• Analyze findings and make recommendations for corrective actions
• Prepare formal documentation for compliance with applicable standards/regulations
• Perform Health Plan Employer Data Information Set data collection (HEDIS)
• Coordinate National Committee for Quality Assurance (NCQA) accreditation activities

Quality Nurse Navigator, RN/LPN

IT Support

• Responsible for overall coordination, status reporting, and stability of project-oriented work efforts
• Develops and monitors project plans, risk management plans, and project documentation from scope to post implementation
• Ensures project documentation and deliverables are complete, on budget, within scope, and in accordance with standards
• Monitors resource requirements based on project specifications
• Responsible for the development, execution, and maintenance of project communications
• Facilitates effective communications between all parties involved in the project
• Identifies the impact of issues arising from the work efforts and/or resource requirements
• Manages the project issues throughout the project life cycle

IT Project Manager

• Audit and authorize reimbursement of specific medical stop loss claims
• Effectively mitigate client medical stop loss claims and provide excellent customer service
• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier
• Recognize cost mitigation opportunities
• Authorize and release stop loss claims reimbursement checks
• Initiate claims investigations and vendor referrals
• Interpret plan language and identify experimental services
• Identify need for follow-up on pended claims and resolution
• Communicate effectively with carriers, vendors, and management
• Provide full claims service to both phone and written inquiries
• Generate and maintain claims system reports
• Develop new and review old stop loss claim forms
• Assist with internal auditing of claims auditors and training of claims auditors

Senior Stop Loss Claims Auditor

General

• Assists with all activities of proposal development.
• Responsible for understanding, and verbally articulating detailed analysis of RFPS, RFIS, RFQS, as well as other documents.
• Assists management by collaborating with Subject Matter Experts (SME), and other staff to create a high quality, winning proposal.
• Coordinates overall proposal process to include intake of customer requests, creating documentation to accompany delegation of required activities to complete proposals, creating and maintaining timeline of activities and packaging the final product for return to customer.
• May assist with sales support activities such as preparing/giving presentations to prospective customers, etc.
• Assists in implementation activities for new groups once they are won and contributes to selected activities that enhance group retention.
• Develops/maintains proposal schedule may plan or outline baselines, and storyboards.
• Develops process/work flows to add value to the marketing statement.
• Assists with the development and compilation of historical corporate data to provide easy access to resources for proposal library and database of information for other proposals as appropriate.

Senior Proposal Specialist

Bilingual

• Cultivates relationships with key partners, stakeholders, and influencers in the community
• Delivers presentations, attends community events/meetings, and distributes materials
• Works with corporate communications team
• Ensures activities are updated, distributed, and in compliance with contracts and mandates
• Plans and executes community/member events
• Executes member growth and retention strategies
• Measures and tracks results and identifies root causes that will enable assigned targets to be met
• Develops and implements community/member outreach and education plans that align with corporate strategic goals
• Researches and identifies new opportunities for community engagement
• Supports and collaborates with various internal teams to ensure corporate goals are met
• Ensures state required marketing activity reports are communicated to management