BlueCross BlueShield of South Carolina

Manager

• Manages the medical review process
• Maintains a well-trained staff
• Develops/implements medical review strategy with the ultimate goal of reducing the error rate
• Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations
• Identifies missed standards and implements corrective actions
• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action
• Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships

Manager, Medical Review – Medicare Appeals, Utilization Review, Part A, HHH

• 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.
• Participates in direct intervention/patient education with members and providers regarding health care delivery system.
• 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 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.

RN Navigator Case Manager – MCC II

Medical Billing and Coding

• Monitor and collect Medicare Stars data to improve health plan ratings
• Conduct specific medical record reviews
• Analyze findings and make recommendations for corrective actions
• Prepare formal documentation for compliance with applicable standards
• Perform Health Plan Employer Data Information Set data collection (HEDIS) and National Committee for Quality Assurance (NCQA) accreditation activities

Medicare Risk Adjustment Coder

Analyst

• Use advanced technologies to design/develop/deploy e-learning solutions via web applications.
• Produce high-quality online learning modules that interface with a learning management system.
• Create content and applies design/graphic principles to educational materials for traditional learning and/or blended solutions.
• Design 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.
• Work closely with support staff and customer to ensure working functionality between e-learning materials, learning management systems, and intranet or internet sites.
• Work with Technical Support Staff to troubleshoot computer and software issues.
• Assist with the design of needs assessments, the development of processes, and the evaluation of program effectiveness.
• Create data management tools to assist in the continuous improvement of training products and services.
• Perform 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.

Senior Workforce Analyst

Claims Specialist

• Independently investigates, evaluates, and negotiates the resolution of assigned claims within approved authority
• Responsible for making recommendations for claim outcomes on claims exceeding level of authority
• Conduct investigations of assigned claims in adherence with corporate timeliness and quality performance standards
• Document activities, case action plans, settlements evaluations and requests for authorizations in the claim notes
• Provide management and internal and external customers with documentation to support recommendations and claim status as required
• Direct the litigation process and work with attorneys to establish defense strategy and case legal budget
• Negotiate settlements with opposing counsel
• Evaluate specials, damages, and/or extent of disability, and negotiate settlement with individual claimants and/or attorneys
• Review independent adjustor's reports and handle claim outcomes.

Claims Adjuster II – Property, Auto, Liability

Auditor

• Performs independent, objective, information systems audits and consulting services
• Conducts timely information systems audits and drafts written reports upon completion of each audit assignment
• Monitors and evaluates information system projects from a risk and control perspective
• Makes recommendations to mitigate risks and improve internal controls
• Reviews disaster recovery plans for all computing environments to ensure they are up to date and functional
• Assists external auditors in completing their audit tasks as a means of maximizing audit efficiency

IS Auditor II

Medical Reviewer

• Evaluate medical records to determine medical necessity
• Perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
• Document decisions using indicated protocol sets or clinical guidelines
• Provide support and review of medical claims and utilization practices
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Monitor process's timeliness in accordance with contractor standards
• Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
• Provide education to members and their families/caregivers
• Review first level appeal and ensure thorough documentation of each determination and basis for each

Medical Reviewer I

Accountant

• Reconciles assigned general ledger accounts of routine to moderate complexity
• Initiates and/or processes journal entries into various accounts
• Performs reviews of various systems activities for Financial and/or Operational reporting
• Prepares financial reports for analysis, forecasting, trending, budgeting
• Performs analyses of financial data to identify problem areas
• Prepares supporting reports/spreadsheets
• Researches/completes account reconciliations
• Resolves out of balance situations
• Maintains documentation of work papers
• Assists with audit preparation and/or review

Accountant II

🌐
Worldwide
Post a Job
Affiliates
❌ Jobs You've Hidden
⭐️ Saved Jobs
✅ Applied Jobs
👤 Account
This job opening is no longer available.
Similar Jobs
Internal Auditor

🕒 March 17

Anthem Blue Cross and Blue Shield

10,000+ employees

⚕️ Healthcare Insurance

☁️ SaaS

🏢 Enterprise

Website
LinkedIn
All Job Openings

Internal Auditor working closely with the Internal Audit Manager at the Bank. Responsible for compliance audits and presenting findings to the Audit Committee.

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

Assistant Manager – High Cost Drug Auditor II

🕒 March 17

EXL

10,000+ employees

Website
LinkedIn
All Job Openings

HCD Auditor II performing remote audits on high cost drug claims using billing expertise. Analyze claims, document findings, and identify trends in healthcare auditing.

🇺🇸 United States – Remote

💵 $50k - $65k / year

💰 $2M Venture Round on 2015-01

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

Senior IT Auditor – PCI QSA

🕒 March 16

Align Technology

10,000+ employees

🧬 Biotechnology

⚕️ Healthcare Insurance

☁️ SaaS

Website
LinkedIn
All Job Openings

Senior Consultant (QSA) leading PCI DSS assessments for A-LIGN, collaborating with high-profile clients across various industries.

🇺🇸 United States – Remote

💰 $105M Series D on 2000-06

⏰ Full Time

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

Senior SOX Auditor, Financial Services

🕒 March 14

Voya Financial

5001 - 10000

💸 Finance

Website
LinkedIn
All Job Openings

Senior SOX Auditor responsible for SOX testing, control evaluations, and external audits in financial services organization. Collaborating with business partners to enhance compliance and control environments.

🇺🇸 United States – Remote

💵 $90k - $120k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

Senior Auditor, Audits and Inspections Program

🕒 March 12

Worldwide Clinical Trials

1001 - 5000

🧬 Biotechnology

💊 Pharmaceuticals

⚕️ Healthcare Insurance

Website
LinkedIn
All Job Openings

Senior Auditor performing QA audits and ensuring compliance for Worldwide Clinical Trials. Leading QA initiatives and supporting Sponsors Audits and Inspections in a remote capacity.

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

Search More Auditor Jobs
🌐
Worldwide
Built by Lior Neu-ner. I'd love to hear your feedback — Get in touch via DM or support@remoterocketship.com
Search
Search Jobs by country
Search jobs by city
Search jobs by job title
Search entry-level jobs
Search junior-level jobs
Search senior-level jobs
Search jobs by tech stack
Search jobs by contract type
Search remote internships
Search remote part-time jobs
Remote jobs Anywhere in the World
Companies Hiring Anywhere in the World
Companies Hiring Sales People Anywhere in the World
Companies Hiring Software Engineers Anywhere in the World
Resources
Advice
Tips for finding remote jobs
Interview questions and answers
Resume examples
Cover letter examples
Post a job
Affiliates
Privacy policy
Terms of service
Job board SEO course
AI Apply Copilot
OpenClaw job finder
Jobs by Country
Remote jobs anywhere in the world (Worldwide remote jobs)
Remote jobs United States
Remote jobs Australia
Remote jobs Brazil
Remote jobs Canada
Remote jobs France
Remote jobs Ireland
Remote jobs Germany
Remote jobs Netherlands
Remote jobs Spain
Remote jobs UK
Popular Jobs
Remote data analyst jobs
Remote customer support jobs
Remote executive assistant jobs
Remote marketing jobs
Remote product designer jobs
Remote product manager jobs
Remote project manager jobs
Remote recruiter jobs
Remote sales jobs
Remote software engineer jobs
Jobs by Type
Remote full-time jobs
Remote part-time jobs
Remote contract jobs
Remote internship jobs
Remote entry-level jobs
Remote jobs with no experience required
Remote junior jobs (1-3 years of experience)
Digital nomad jobs
Remote jobs with no degree required
Freelance remote jobs
Temporary remote jobs
Remote jobs hiring now
Stay at home mom jobs