BlueCross BlueShield of South Carolina

Manager

• Manages daily service/administrative-related activities to include paperwork, administrative/service requests, weekly and monthly activity/production reports, etc.
• Analyzes program effectiveness and appropriate use of technology, and develops/implements/oversees overall marketing strategies, programs, and/or events.
• Monitors the marketplace to identify trends in sales, competitors, product designs and reports this data to management.
• Prepares and supervises the implementation of plans for new products.
• Trains staff, vendors, and program personnel in product knowledge and assists staff in developing technical servicing skills.
• Performs quality control functions for work performed and makes recommendations on process improvements.
• Recruits/selects/develops/guides staff and ensures excellent customer service is given to employees, customers, management, etc.
• Monitors department performance and productivity.
• May develop policies/procedures and communicates any changes/updates to staff.

Manager, Large Group Market

• 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

Concierge Care Manager

Account Manager

• Serves as primary contact for clients
• Handles less complex clients and works with other Relationship Managers, Consultants, Client Advocates, NA Operations and Support, Reporting Medical Management, Product Development, etc. and Partner Plan Account Managers to meet client needs and resolve client issues
• May participate in the implementation of new clients
• Assists in the assessment of client specific benefits to determine set up in the Group Library ensuring coded correctly
• 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 before submission to the client

Client Relationship Manager

• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria
• Applies clinical expertise and Administrative policies to service requests
• Provides health management program interventions
• Assesses, plans, implements, coordinates, monitors, and evaluates medical necessity options and services
• Promotes quality, cost effective outcomes
• Provides telephonic support for members with chronic conditions or high-risk pregnancy
• Conducts intensive assessment/evaluation and at-risk education
• Engages members through motivational interviewing and reflective listening
• Identifies and participates in on-site reviews
• Serves as member advocate through communication and education
• Promotes enrollment in care management programs
• Ensures accurate documentation of clinical information
• Participates in data collection/input into system for clinical information flow

Behavioral Health Case Manager II

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
• Conducts interviews with key personnel
• Conducts testing, evaluates internal controls, analyzes existing financial and management practices to determine effectiveness, and reviews relevant documentation to support findings
• Develops detailed reports on each audit conducted, including a review of findings and recommendations to correct deficiencies and improve processes
• Conducts testing of corrective actions as identified
• Conducts special audit studies for management to identify controls for prevention of fraud
• Prepares reports of findings and recommendations for management
• Assists other auditors in completing their assignments to maximize audit efficiency

Auditor I, CGS

Analyst

• Conducts market/product/competitor research to be used in development of new products.
• Completes all marketing Requests for Proposals (RFPS)/Request for Information (RFIS) for CHC marketing, Major Group marketing, BlueChoice, and other divisions/cost centers.
• Develops/maintains databases of information for the RFPS and RFIS.
• Collects/analyzes market data and provides management with reports.
• Ensures that proposal responses are accurate, consistent, and responsive and promotes the advantages of our products and services.
• Retrieves information from all functional areas of the health plan and develops/maintains/updates database for these proposal databases.
• Collects/analyzes statistical data regarding proposal activity, and existing/potential products and markets.
• Designs/prepares/generates and maintains reports that utilizes data to forecast future market conditions and customer preferences.
• Provides management with detailed reports and makes recommendations for improvement.

Market Proposal Analyst II

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 inquiries
• Handle situations which may require adaptation of response or extensive research
• Accurately document inquiries
• Initiate or processes adjustments or perform other research as needed
• Coordinate with other departments to resolve problems
• Provide feedback to management regarding customer problems, questions and needs
• Maintain accurate records on complaints and/or other customer comments
• Follow through on complaints until resolved or report to management
• Assist with process improvements through the recommendation of changes in procedures

Customer Service Advocate I

General

• Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy.
• Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools.
• Updates letter's and documents within the department when necessary.
• May gather and prepare documentation for legal inquiries and administrative requests.

Appeals Specialist – CGS Admin

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 medical policies
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and statistical data related to medical service utilization
• Conducts research into new or controversial medical procedures and technology

Physical Medicine and Rehabilitation Medical Director

• Provide prompt, accurate, thorough and courteous responses to customer inquiries
• Perform research as needed to resolve inquiries
• Ensure effective customer relations by responding accurately, timely and courteously to inquiries
• Accurately document inquiries
• Initiate or process adjustments or perform other research as needed to resolve inquiries
• Coordinate with other departments to resolve problems
• Provide feedback to management regarding customer problems, questions and needs
• Maintain accurate records on complaints and/or other customer comments
• Make recommendations for changes to management
• Follow through on complaints until resolved or report to management as needed
• Assist with process improvements
• Identify and promptly report suspected fraudulent activities and system errors

Customer Service Advocate II

Designer

• Oversee and approve, in coordination with Design Architects, the design of the business or technical solution
• Ensure team members understand the business requirements that drive the analysis and design of quality technical solutions
• Responsible for solutions, spanning more than one platform and/or customer area
• Lead the design of software solutions, utilizing appropriate software engineering processes in coordination with project teams
• Develop artifacts such as concept diagrams, technical diagrams, and cost and budget calculations and coordinate/combine those created by System Designers
• Present design solution options to Design Architects and upper management for sign off for projects spanning multiple platforms and/or customer areas
• Lead design sessions with project teams, and resolves issues that arise between the teams
• Recognize, identify, and communicate overlaps with projects and efforts
• Stays abreast of all facets of each project, ensuring the health of each project throughout the project life cycle
• Communicate design solutions to internal and external customers and project teams
• Build and maintain the technical, business, and architectural knowledge
• May mentor development and design staff

Solution System Designer

Software Engineer

• Write or debug programs to maintain and control computer systems software, such as operating systems, networked systems, and database systems
• Provide technical and disaster recovery support for systems software
• Research and analyze complex systems software problems and issues to implement workable solutions or escalate as appropriate
• Install, test, and maintain systems software including installing updates, upgrades, and patches
• Initiate tests of system programs and observe results to detect errors or work stoppage
• Modify code to correct errors
• Assist in internal and external audits being performed across multiple lines of business for multiple platforms
• Participate in planning and execution of disaster recovery procedures
• Cross train in all areas of systems programming to efficiently perform on-call rotation

Mainframe System Programmer, Level III

Accountant

• Responsible for analyzing and researching complex healthcare and financial data to identify, investigate, and resolve variances within Medicare Cost Reports.
• Ensures accurate determination of settlements and reimbursement rates while maintaining compliance with regulatory requirements and meeting all reporting deadlines with accuracy and timeliness.
• Reconciles assigned accounts.
• Initiates and/or processes general ledger, and/or journal entries into various accounts.
• Prepare spreadsheets and/or ensures that entries are entered into the accounting system.
• Assist coworkers in preparation and/or review of daily activity, monthly, quarterly and/or annual filings as required by regulatory agencies and/or internal requirements.
• Prepares reports for financial analysis, forecasting, budgeting, trending, and/or results analysis to ensure transactions in the ledger tie to statistical files and/or various financial reports.
• Performs analysis of financial data to identify problem areas and/or report to management.
• Maintains accurate general ledger (G/L) accounts.
• Assists with special projects as assigned by the manager to include coordination between areas and allocation of resources.

Accountant I, Medicare

Chief Marketing Officer

• Solicits actively for new distribution outlets for Companion Life's products
• Motivates general agents and brokers through visits and seminars to market products
• Formulates, advises, and implements policies necessary to enhance production profitability and service standards
• Develops marketing and sales themes, promotions, and sales materials
• Monitors loss ratios and persistency and implements corrective actions
• Develops and or enhances new/existing group products
• Recommends pricing, product design, filing, direct mail, and compliance requirements
• Manages all aspects of marketing, sales, renewal, and servicing of Companion Life's products from a field office environment, without benefit of on-site marketing support staff

Director, Ancillary Sales & Marketing Representative

• Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy
• Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools
• Updates letters and documents within the department when necessary
• May gather and prepare documentation for legal inquiries and administrative requests