BlueCross BlueShield of South Carolina

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.

Sales Representative

Actuary

• Intern position utilized for training an active high school or college student towards an entry-role
• Responsibilities vary and are based upon the needs of the area and the experience of the incumbent at the time of employment
• This incumbent works under direct supervision and has responsibilities for performing entry-level tasks and for learning professional-level tasks relating to area operations
• May assist with the implementation of various activities and programs for assigned business units within the organization
• Participates in business unit/department training designed to help this position acquire applicable knowledge/skills in their area of study
• Completes area tasks that are conducive to learning the departmental procedures and applying industry/field best practices
• May communicate with other areas of the company
• May conduct research and analysis of various reports (monthly, quarterly, annually)
• Perform tasks that help in learning the business area and which provide an overall view of company operations
• Assist other staff members with everyday tasks to gain an understanding of business operations and workflow
• Completes other assigned area related tasks
• May identify areas of need improvement and communicates to management.

Actuarial Intern

Accounting Manager

• Prepares various financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function.
• Ensures data is complete, accurate, and organized for processing.
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
• Completes moderately difficult research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds.
• Resolves routine questions and problems, referring complex issues to higher levels.
• Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
• Provides other support duties related to the accounting/finance function that may include monitoring financial systems, keying journal entries, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc.
• May assists less experienced accounting clerks as needed.
• Determines, prepares, and distributes correspondence regarding monies due or erroneously received.
• Issues refunds as appropriate.

Accounting Technician II, Medicare

QA Engineer

• Supervises staff in conducting timely quality control audits for one or more functions; claims, customer service inquiries, membership, coordination of benefits, refunds, billing, etc.
• May also supervise staff in completing special projects including system changes.
• Mediates and negotiates staff conflicts, makes hiring, disciplinary and performance decisions and sets department goals or standards.
• Determines training priorities and coordinates internal training activities as needed.
• Identifies and recommends procedural enhancements to improve quality and minimize financial loss to the corporation.
• Prepares and reviews reports and analyses providing interpretation of production and quality standards.
• Maintains and updates desk procedures to ensure quality and minimize processing errors.

Supervisor, Quality Assurance

Marketing

• Responsible for directly managing staff in the planning, coordination, implementation and maintenance of diverse projects.
• Focuses on meeting project commitments, including communications with sponsors, stakeholders, etc.
• Provides staff direction for area projects, training, auditing, testing, research and analysis, quality management, business change mandates, system enhancements, quality control activities, strategic planning, performance monitoring, compliance activities.
• Identifies business requirements.
• Supports new business implementations or acquisitions.
• Facilitates the definition of project missions, goals, tasks, resource requirements, service levels, and customer requirements.
• Maintains effective communication with stakeholders during all phases of projects.
• Resolves or assists in the resolution of conflicts within and between projects or functional areas.
• Ensures compliance, performance standards, and improvement of procedures and processes.
• Assists in the identification of potential process improvements and cost savings.
• Manages project budget and resource allocation including scheduling, planning, reporting, development and implementation within timelines and budgets.

Marketing Projects Manager

Customer Support

• Responds accurately, timely, and courteously to customer inquiries
• Handles non-routine inquiries requiring research
• Reviews and adjudicates claims and appeals
• Determines claim outcomes following policies
• Ensures claims are processed according to established standards
• Identifies and reports potential fraud

Claims Customer Service Advocate II

• Responsible for responding to customer inquiries.
• Perform research as needed to resolve inquiries.
• Review and adjudicate claims and/or non-medical appeals.
• Determine whether to return, deny or pay claims following organizational policies and procedures.
• Ensure effective customer relations by responding accurately, timely, and courteously to inquiries.
• Handle situations which may require adaptation of response or extensive research.
• Identify incorrectly processed claims and process adjustments and reprocessing actions.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensure claims are processing according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution.
• Identify and report potential fraud and abuse situations.

Software Engineer

• Responsible for analysis, design, programming, and implementation of 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.
• Review detailed specifications and recommend modifications.
• Design, code, test and debug complex application programs.
• Produce deliverables related to the assigned project.
• Perform analysis, design, programming, and implementation of systems and procedures to solve complex business or scientific problems.
• Evaluate interrelationships in immediate programming area to determine how changes in one program will affect another related area.
• Apply conversions and enhancements to business systems.
• May lead or provide expertise on assigned projects.
• Work closely with customers, business analysts, and team members to understand business requirements that drive the analysis and design of quality technical solutions.
• Ensure solutions are aligned with business and IT strategies and comply with the organization’s architectural standards.
• Assist in post-implementation support and system enhancements.
• Test modified programs, create necessary test files and data, verify logic, debug, and write relevant documentation.
• Design and develop IT systems.
• Devise new sources of data and develop new approaches and techniques.
• Involved in the full systems life cycle and is responsible for designing, coding, testing, implementing, maintaining and supporting complex application software that is delivered on time and within budget.
• Provide guidance to lower-level programmers/analysts.
• Act as an internal consultant by providing technical guidance on complex projects.
• Determine and resolve problems with other systems analysts, programmers, and systems users.
• Test designed programs, verify logic, perform any necessary "debugging," and write the documentation.

Developer IV

Project Manager

• Administers various projects and assists management in the overall functioning of the business area.
• Identifies procedural/system issues affected by implementation of project initiatives.
• Makes recommendations for change/development, both technically and operationally.
• Provides monitoring of key operating statistics.
• Follows up with all changes, improvements and processes to ensure compliance and effectiveness.
• Assists in the creation and implementation of work improvements and action plans for the department related to critical business processes and/or customer service related requirements.
• Assists in the creation and implementation of plans and programs to assure staff is following all established and new processes/policies.
• Prepares written instructions, presentations, etc. and administers training for staff members.
• Provides effective feedback and develops work instructions and job aids to assist the staff in understanding any impact to daily job responsibilities.
• Responds to issues or concerns from internal/external support areas.
• Coordinates activities among division functional areas.
• Prepares and analyzes specialized reports for staff as it relates to the progress of new projects and initiatives.
• Maintains effective relationships with internal/external entities by leading and participating in meetings, conferences, workshops and professional organizations, ensuring necessary information is received/delivered in order for business unit objective to be met.

Project Administrator

Manager

• Provides active case 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 that consist of: intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
• May identify, initiate, and participate in on-site reviews.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determinations.
• 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.
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies.

RN Navigator Case Manager – MCC II

Operations

• 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

Operations Analyst

Sales

• Provide dedicated support for the Request for Proposal (RFP) process, including strategic input on sales strategy responses, coordination during peak seasons, and ensuring timely, high-quality submissions
• Secure, track, and maintain client references and performance guarantees to build a robust library of social proof and market intelligence
• Identify, analyze, and implement improvements to core sales processes
• Focus areas include enhancing workflows with key partners and refining sales transition processes, including meticulous tracking and reporting
• Conduct comparative analyses of performance guarantees across various markets, industries, and consultants
• Track trends to help standardize and improve market-specific offerings and inform strategic decision-making
• Assist in developing high-impact sales presentations, pitch decks, and supporting materials
• Provide timely assistance with follow-up questions from prospects and clients, ensuring clarity and consistency in communication
• Establish and maintain positive Partner Plan distribution channel relations
• Manage working relationship with Partner Plans including legal, policy and procedures and issue resolution
• Gather and synthesize market and competitive intelligence to help the sales team better position our offerings
• Monitors marketplace regularly to identify trends in sales, competitors, BlueCross BlueShield Association initiatives and product design
• Sends/shares data to senior management and Partner Plans for review on a regular basis

Sales Enablement and Support Advisor

Customer Retention Specialist

• Responsible for the successful marketing (sales, renewals, and/or service) of group and/or individual accounts for products as defined by production quotas within assigned territory
• Customarily and regularly engaged in outside 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, 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.

Medicare Advantage Retention Specialist I

Data Analyst

• Creates and analyzes reports to support operations.
• Ensures correctness of analysis, and reports findings in a concise manner to senior management.
• Generates internal and external reports to support management in determining productivity and efficiencies of programs or operational processes.
• Revises existing reports and develops new reports based on changing methodologies.
• Analyzes reports to ensure accuracy and quality.
• Tracks and verifies all reporting statistics.
• Communicates and trains employees and managers on the complex database programs used to generate analytical data.
• Designs, codes, and maintains complex database programs for the extraction and analysis of data to support financial and operational decisions.

Data Analyst III

Auditor

• Conducts internal and/or external timely operational, financial, and/or compliance audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls
• Identifies, documents, and evaluates business risks
• Develops written audit programs
• Conducts testing and analysis of existing controls to determine adequacy and effectiveness
• Prepares written work papers to document testing results and conclusions reached
• Documents issues, the causes of those issues, and their effects on the process/function and the corporation
• Serves as Lead Auditor on more complex audit assignments
• 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
• Provides training to and assists or leads other auditors

Sales Representative

Actuarial Intern

Accounting Technician II, Medicare

Supervisor, Quality Assurance

Marketing Projects Manager

Claims Customer Service Advocate II

Claims Customer Service Advocate II

Developer IV

Project Administrator

RN Navigator Case Manager – MCC II

Operations Analyst

Sales Enablement and Support Advisor

Medicare Advantage Retention Specialist I

Data Analyst III

Auditor III