BlueCross BlueShield of South Carolina

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, Maternity Focus

General

• Maintain all quality management system documentation at the company level
• Assist and train functional document control administrators and management in documenting procedures in accordance with certification standards
• Provide support for the Quality Management System (QMS)
• Provide weekly metrics on new, in progress, and completed medical records requests
• Manage, organize, copy, scan, and analyze medical records to ensure accuracy, integrity, and timely fulfillment of medical record requests
• Travel to providers offices to complete medical record requests via Electronic Medical Records Systems
• Manage electronic and physical records, ensure compliance with federal regulations and agency directives, and support the full records lifecycle from creation to disposition
• Stay up-to-date with medical records and health information release regulations (e.g., HIPAA) to ensure accurate processing
• Provides document control administrator and management training and support for QMS
• Ensure all document control procedures are understood, followed, and improved as needed
• Update ISO 9000 and quality management documentation at the company level
• Maintain files, records, and documentation in accordance with certification standards
• Work with vendor, document control administrators, and management to maintain and enhance the QMS documentation system as well as to maintain, develop and test any enhancements
• Compile performance metric reports, management review reports, and score cards
• Provide documentation control for management review meetings
• Prepare and distribute minutes and task list
• Plan internal/external audits
• Perform documentation audits for auditors
• Document audit findings in a final report presentation

Records Coordinator

Auditor

• Conducts internal and/or external timely operational, financial, and/or compliance audits
• Identifies, documents, and evaluates business risks
• Develops written audit programs
• Conducts testing and analysis of existing controls
• Prepares written work papers to document testing results
• Documents issues, causes of those issues, and their effects
• Serves as Lead Auditor on complex audit assignments
• Drafts recommendations to limit risks and improve processes
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls
• Conducts testing of corrective actions
• Develops detailed reports on each audit conducted
• Examine and evaluate financial and information systems
• Conducts special audit studies for management
• Provides training to other auditors

Auditor III

• Conducts internal and external timely operational, compliance, and financial audits
• Identifies, documents, and evaluates business risks
• Drafts recommendations to limit risks and improve processes
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls, 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

Medicare Cost Reporting Auditor II

• 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

Analyst

• Analyzes server workload, including traffic and utilization trends.
• Provides analytical support to team members throughout the development and implementation process.
• Provides feedback on commonly encountered problems and misunderstandings to enhance user documentation and/or training programs etc.
• May provide training on hardware and/or software use.
• Compiles and analyzes operational data and directs tests to assist in establishing standard for new designs or modifications to existing equipment, systems, or processes.
• Tests and verifies servers and support peripherals to ensure that they meet specifications and requirements, by recording and analyzing test data.
• Confers with technical specialists and consults specifications to evaluate interface between hardware and software and operational and performance requirements of overall system (s).
• Interfaces with users, consultants, technical teams, and vendors for maximum guidance or on new technology to determine installation requirements.
• Ensures compliance with audit requirements.
• Addresses vulnerabilities within audit-mandated time frames.
• Anticipates and mitigates problems to integrity the security of the system.
• Maintains effective security/backup and disaster recovery processes and systems.
• Monitors server performance to determine whether adjustments need to be made, and to determine where changes will need to be made in the future.
• Creates and maintains process and procedure documentation.
• Keeps knowledge and skills updated to keep up with rapid advancements in server technology.

Server Analyst

Data Analyst

• 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.

Digital Data Analyst

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, 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
• Monitors process’s timeliness in accordance with contractor standards
• 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

RN Medical Reviewer II

• 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.

RN Case Management Coordinator – NICU, Maternity

• Develops, implements, evaluates, and maintains health management programs
• Positions BCBSSC to compete effectively with other companies
• Achieves positive return on investment through oversight of new product/technology development and promotion of service enhancement strategies to increase customer retention
• Develops and conducts health management presentations to management, internal and external customers that are informative and customized to meet health plan and customer needs
• Establishes reporting mechanism that details clinical outcomes, utilization statistics and ROI
• Develops and maintains specific reporting to include tracking of efficacy, clinical/financial outcomes, research analysis, and the accuracy/timeliness of data collection
• Provides leadership and direction to staff through employee development, management training, and budget oversight
• Develops, implements, complies with and promotes staff adherence to corporate and department policies, procedures, and performance and communication standards
• Complies with and monitors adherence to URAC case management standards, SC Department of Insurance regulations, SC Nurse Practice Act, all applicable state and federal laws and standards of national accreditation agencies, as management deems necessary

Cost Containment and MLR Optimization Program Lead

Medical Director

• Provides administrative oversight to medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policy issues
• Writes and revises medical policies
• Supports operations in case review on medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on medical policy and program administration
• Develops and updates medical policies in consultation with regulatory personnel and consultants
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and other statistical data
• Conducts research into new or controversial medical procedures and technology

Physical Medicine and Rehabilitation Medical Director

Systems Engineer

• Direct the analysis, development, and operation of computer systems
• Devise feasible logical procedures to resolve business problems through the efficient use of computer resources
• Perform all phases of applications systems analysis
• Review systems specifications and recommend applications to support information systems processes such as legacy data migration, integration and testing
• Prepare detailed specifications from which complex programs can be written
• Design, code test, debug, document and maintain systems software
• Formulate scope and objectives through research to develop, modify and improve complex systems

Systems Analyst, Software Engineer

• Design, code, maintain and executes simple to complex programs for the extraction, analysis and presentation of data for standard and ad hoc reporting.
• Assist with development of complex statistical analysis and models to identify datasets and analyze data.
• Provide 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.
• Verify data in existing databases and assists in the collection of data and management of existing databases.

Statistical Programming Analyst

• Provides leadership and medical support on medical and regulatory matters.
• Identifies trends in medical and pharmacy costs, utilization trends, and proactively makes recommendations and initiates solutions to impact these.
• Provides leadership to clinical team and operations in order to increase compliance, improve efficiency, and increase communication.
• Acts as resource for providers, staff, part time medical reviewers, and as requested, customers, on issues concerning medical policies and regulations.
• Provides clinical support to Payment Integrity Unit(s) to analyze abuse patterns and recommend solutions.
• Provides oversight and leadership with quality improvement and health plan and medical program accreditation(s).
• Works with staff and other leadership in developing ideas related to quality initiatives, good clinical support, and outreach to the network.
• Responsible for physician review (UM, Appeals, CM) - reviews physician and provider practice pattern analysis and other statistical data.
• Conducts research into new or controversial medical procedures and technology.
• Educates staff, network providers, and medical community on various aspects of medical policy and program administration.

Case Management Coordinator, Maternity Focus

Records Coordinator

Auditor III

Medicare Cost Reporting Auditor II

Senior Stoploss Claim Auditor

Server Analyst

Digital Data Analyst

RN Medical Reviewer II

RN Case Management Coordinator – NICU, Maternity

Case Management Coordinator, Maternity Focus

Cost Containment and MLR Optimization Program Lead

Physical Medicine and Rehabilitation Medical Director

Systems Analyst, Software Engineer

Statistical Programming Analyst

Behavioral Health Medical Director