BlueCross BlueShield of South Carolina

Medical Reviewer

• Performs 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, and correct coding for claims/operations
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Documents medical rationale to justify payment or denial of services and/or supplies
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participates in quality control activities in support of the corporate and team-based objectives
• Provides guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback
• Assists with special projects and specialty duties/responsibilities as assigned by Management

Medical Reviewer III – Home Health and Hospice

Account Specialist

• Serves as team lead and is responsible for coordinating area processes/tasks to include the following: distribution of work, logging access database, processing group changes, responding to inquiries, training new employees, preparing reports/books/contracts
• Coordinates and ensures prompt processing of enrollment of new groups, renewals, changes, and cancellations of assigned groups under private business
• Trains and motivates new employees
• Assigns work and monitors work/workload of staff
• Serves as team lead and expert on account administration
• Coordinates with marketing, underwriting, claims, benefit files, and other areas to ensure relevant/appropriate group structure/status/benefits/billing
• Prepares and issues contracts and benefit books
• Drafts custom language as requested and coordinates with printing and graphics for finished products
• Prepares and issues standard and custom id cards
• Coordinates with marketing and data control to design custom cards
• Responds to all inquiries and advises/resolves group and/or member problems
• Prepares/maintains accurate group files
• Coordinates/ensures prompt, accurate processing of the billing/payment processes
• Prepares/submits area reports for management

• Perform medical claim reviews for claims requiring preauthorization or appeals
• Determine medical necessity and appropriateness for coverage and reimbursement
• Document medical rationale for payment or denial of services
• Educate staff on medical reviews, coverage determinations, and coding procedures
• Participate in quality control activities

Reviewer II, Medical

General

• Screens applications to ensure accuracy of data entered into system and updates system with status of pending applications.
• Uses underwriting guidelines to make initial decisions to approve, decline, or assign received applications.
• Analyzes, rates, and processes new business proposals according to established guidelines.
• Provides quality customer service, responding accurately and timely to telephone and written inquiries from customers.
• Assists in establishing and maintaining written procedures for underwriting review.
• Prepares departmental reporting as needed.
• Prepares stop loss proposals and forwards to stop loss carriers for quotes.

Group Underwriter, I

Medical Assistant

• Provides health coaching or intervention telephonically or in person for assigned health programs.
• Utilizes all data systems containing patient information and documents information appropriately.
• Assists with the identification of areas for which there is a need for health management programs.
• Monitors quality indicators and develops programs to positively impact areas where improvement is warranted.
• Develops patient/provider educational materials for members/providers.
• Assists with implementation of health management activities/programs for membership.
• Facilitates program to participants and focuses emphasis on medium-risk patients.
• Follows/updates established procedures.
• May conduct research and analysis of reports (monthly, quarterly, and annually).
• Assists with the development of strategies to increase effectiveness of and participation in health management programs.
• Establishes/maintains effective communications with provider network, group, representatives, and members.

Sales

• Leads the sales, renewal, and service operations for the assigned region
• Provides strategic leadership to a high-performing team
• Develops, implements, and manages marketing strategies for assigned region
• Monitors marketplace to identify trends in sales, competitors or product design
• Develops and maintains excellent relationships with business partners, vendors, potential business partners, groups, agents, and brokers.

Regional Sales Director

Case 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 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, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal)
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately
• Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services

Case Management Coordinator, Social Worker

• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Provides support and review of medical claims and utilization practices.
• May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.
• Monitors process's timeliness in accordance with contractor standards.
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Performs screenings/assessments and determines risk via telephone.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives.

Medical Reviewer I

Insurance

• Oversees functions of a line of business, which may include underwriting and sales.
• Establishes critical metrics and objectives to ensure high performance and corporate compliance.
• Develops customs and marketing strategies, and builds relationships with brokerage networks, sales, line of business management, and underwriting.
• Develops sound financial goals and objectives for the line of business and monitors progress toward stated goals and objectives.
• Ensures competitiveness and growth of the company by working with external agents and staying abreast of market conditions relevant to the line of business.
• Assists in building and maintaining reinsurance relationships.
• Establishes strong relationships with brokers/agents to achieve the highest level of integrity.
• Maintains standards of quality and broker/agent satisfaction.

Product Executive

• Researches requests, enters appropriate data to identify case specifics, builds appeals cases on the system
• Logs requests to appropriate functional area, generates letters, assembles files, orders records and obtains additional information as directed
• Ensures quality control of all appeals on the appeals system
• Pends documents to be saved electronically
• Prepares case files for review and/or further routing

Coordinator, Appeals

Product Specialist

• Manages external vendor after launch and implementation to include group onboarding, sales training, resolution of member level issues and client/vendor invoicing
• Analyzes and coordinates submission of aggregate executive summaries regarding efficacy of the product/program that are both client facing and line of business specific
• Develops, coordinates, evaluates, and provides customer support for activities/programs
• Creates member feedback collection methods, monitors member satisfaction and improves services to enhance customer experience
• Maintains training and marketing materials
• Builds and maintains strong relationships with external companies and internal Lines of Businesses
• Maintains detailed procedures/documentation of data sources and all related product methodology
• Responsible for developing and implementing policies/procedures, onboarding, and invoicing
• Prepares charts, illustrations or other graphic presentations, as well as narrative analysis
• Monitors/interprets trends and offers solutions to address emerging healthcare utilization trends
• Additional tasks, projects as assigned

Product Consultant

Auditor

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation
• 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, 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
• Reviews findings and identifies recommendations to correct deficiencies and methods for process improvements
• Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity
• Conducts special audit studies for management to discover controls for fraud prevention
• Prepares reports of findings and recommendations for management

Medicare Cost Reporting Auditor II

• 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
• 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 in completing their assignments as a means of maximizing audit efficiency

Medicare Cost Reporting Auditor III

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas.
• Provides leadership/guidance/direction/training to staff.
• Maintains a working knowledge of unit functions and the ability to interpret to new hires.
• Acts as a resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads.
• Participates in departmental quality reviews.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested by management.

Senior Medical Reviewer

• Functions as team leader/senior-level Medical Reviewer.
• Provides leadership/guidance/direction/training to staff.
• Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow.
• Acts as resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews.
• Follows process to ensure quality plan is adhered to and communicated to all parties.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries.
• Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested by management.