BlueCross BlueShield of South Carolina

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
• Handle situations which may require adaptation of response or extensive research
• 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 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
• Assist with the training of new employees and cross-training of coworkers

Customer Service Advocate I

Software Engineer

• Responsible for the analysis, design, programming, and implementation of complex application tasks and projects
• Devise feasible, logical procedures to resolve business problems through the effective use of technology
• Formulate scope and objectives through research to develop or modify complex systems
• Design, code, test, and debug complex application programs
• Collaborate with customers, business analysts, and team members to understand business requirements
• Test modified programs, create necessary test files and data, verify logic, debug, and write relevant documentation
• Provide guidance to lower-level programmers/analysts
• Act as an internal consultant by providing technical guidance on complex projects

Mainframe COBOL Developer IV

Auditor

• Conducts internal and external timely operational, compliance, and financial audits
• Evaluates 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
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance
• Conducts testing of corrective actions
• Develops detailed reports on each audit conducted
• Examines and evaluates financial and information systems
• Conducts special audit studies for management
• Prepares reports of findings and recommendations for management
• Assists other auditors in completing their assignments

Durable Medical Equipment Auditor

Analyst

• Research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal 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.
• Document the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• Perform 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.
• Perform 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.
• Perform special projects including reviews of clinical information to identify quality of care issues.

RN Appeals Analyst

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

Ecommerce

• Oversee user experience (UX) design ideation, and iteration, while ensuring the team adheres to best practices
• Provide strategic direction in the development of testing approaches, including strategy, participant recruitment, and leveraging vendors and/or technology in the process
• Enable the UX design process through strategic evaluation, acquisition, and management of technology/tools
• Provide project support, to include translating design into project requirements, effectively communicating business needs, managing deadlines and team deliverables, and supporting implementation
• Oversee the development and deployment of digital content across platforms to ensure editorial consistency and adherence to brand and corporate digital guidelines
• Partner with team members to develop, implement, and communicate digital governance practices
• Responsible for member engagement strategy and omni-channel content development
• Responsible for recruiting and hiring, coaching and mentoring, monitoring and evaluation, and addressing all disciplinary issues in a timely manner
• Encourage staff in creating and maintaining a work environment with a high morale and employee satisfaction through support of professional development, training, career growth, and rewarding high performance
• Conduct market and design research in support of digital strategy efforts
• Monitor industry trends incorporate best practices into work processes and communicate findings to leadership to ensure competitiveness in the market
• Manage relationships with vendors, internal stakeholders, and I/S to ensure alignment on digital priorities, DX-driven communication strategies, and the successful execution of projects

Digital Experience Design Manager

Marketing

• Responsible for planning, development, direction, and management of all activities related to product and program development for assigned division's business.
• Determines the demand for new or enhanced product, programs and services through market research and analysis.
• Responsible for the development of new/enhanced products and programs from idea generation to implementation.
• Projects market potential and estimate market penetration.
• Tracks financial information on the performance of products and programs.
• Maintains relationships with outside product vendors.
• May manage, direct, and/or develop any or all of the following in administration/support of product and program development for assigned division's business.
• Manages the collection, analysis and preparation of tracking reports for sales information and/or contests.
• Develops and implements technology strategies that support assigned division.
• Directs development of Web related applications as it relates to division.
• Manages activities of staff engaged in supporting market research, product development, sales reporting, and Web site management.
• Responds/reviews RFPs/RFIs.

Marketing Manager, Product and Programs

Medical Reviewer

• 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, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determine medical necessity and 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/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participate in quality control activities in support of 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/responsibilities as assigned by management

Medical Reviewer III

Manager

• Manages day-to-day operations of credentialing area to include delegated credentialing activities.
• Develops/implements credentialing policies/procedures/evaluation tools.
• Evaluates/monitors/ensures compliance with National Committee of Quality Assurance (NCQA) and other regulatory standards/external review bodies.
• Conducts on-site audits and inspections of delegated entities/provider files.
• Communicates with/responds to internal and external representatives regarding data, delegation agreements, facility credentialing, and sanction issues.
• Works with other departments to address/resolve credentialing issues.
• Promotes efficiency through planning, problem solving, and application of industry standards.
• Maintains accurate/current/efficient databases.
• Coordinates/manages all activities and follows-up for credentialing committee.
• Presents physicians/practitioners/providers with quality issues to committee for review.
• Selects/trains/develops/guides staff and ensures excellent customer service is given to employees/customers/management, etc.
• Monitors department performance and productivity.
• Performs quality control functions for work performed.
• Makes recommendations on process improvements and identifies training needs for staff.

Credentialing Manager

• Promotes blended learning solutions and the use of innovative technology and tools to meet business goals of developing a high-performing workforce
• Produces web-enabled e-learning, traditional educational materials, or a blended solution using leading-edge technology
• Uses advanced technologies to design/develop/deploy e-learning solutions via web applications
• Produces high-quality online learning modules that interface with a learning management system
• Creates content and applies design/graphic principles to educational materials for traditional learning and/or blended solutions
• Designs and updates e-learning using unique combinations of cutting-edge interactive media, state-of-the-art techniques, electronic tools and systems
• Evaluate and revise materials based on the effectiveness of training programs and curriculum
• Test, problem-solves, updates and maintains e-learning, traditional and/or blended learning solutions
• Works closely with support staff and customer to ensure working functionality between e-learning materials, learning management systems, and intranet or internet sites
• Works with Technical Support Staff to troubleshoot computer and software issues
• Assists with the design of needs assessments, the development of processes, and the evaluation of program effectiveness
• Creates data management tools to assist in the continuous improvement of training products and services
• Performs duties that may include customer conference calls, planning meetings, action items, professional development seminars, tasks related to certification, training others and/or special projects
• Assume project management responsibilities for both internal and external clients/customers, related to e-learning training program design, development, and deliverables

e-Learning Designer – Developer

• Serves as a team lead in the membership and/or customer service area
• Responsible for coordinating area processes/tasks including distribution of work, database entries, responding to inquiries, training new employees, preparation of reports
• Coordinates and ensures distribution and prompt processing of all paperwork for document production
• Coordinates workflow processes
• Proofs departmental documents prior to authorizing release
• Assists supervisor with preparation and maintenance of group and electronic files
• Works closely with quality control, marketing, printing, and other internal/external customers to ensure quality and timeliness of work produced
• Assists supervisor with problem resolution and coordinates processes with internal departments and internal/external customers
• Participates and completes special projects as assigned by management
• Audits departmental document database to ensure timeliness standards are met
• Performs quality control audits on work performed and document production
• Trains and motivates new employees
• Assigns work and monitors work/workload of staff

Membership/Customer Service Coordinator

• Audit and authorize reimbursement of specific and/or aggregate 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 at or below pre-set authority limits.
• Initiate claims investigations and vendor referrals.
• Interpret plan language, and identify experimental services and subrogation opportunities.
• 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 to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
• Develop new and review old stop loss claim forms.
• Assist with internal auditing of claims auditors, and training of claims auditors.

Senior Stoploss Claim Auditor

• Provides prompt, accurate, thorough and courteous responses to all customer inquiries
• Handles situations which may require adaptation of response or extensive research
• Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines
• Examines and processes claims and/or non-medical appeals 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
• 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

Customer Service Advocate II

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

• Develops comprehensive reports and analyzes data in order to identify patterns and trends
• Assists in creating materials that aid in illustrating analytical/data findings
• Identifies opportunities for improvement that can be addressed with educational initiatives
• Uses multiple software platforms to produce reports in accordance with work requests, internal initiatives, and requests from customers
• Codes, maintains, and executes simple to complex database programs for the extraction and presentation of data for standard and ad hoc reporting
• Develops supporting material and guidelines on report design and resulting data
• Evaluates data integrity to assure compliance with customer requirements and makes recommendations for corrective and preventative actions
• Provides input on database design
• Illustrations, other graphics, and narrative reports to identify and explain patterns and trends
• Assists with performing quality checks on new and existing relational database changes
• Creates support documentation outlining procedures