BlueCross BlueShield of South Carolina

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

Customer Support

• Responsible for responding to routine inquiries
• Identifies incorrectly processed claims and completes adjustments and related reprocessing actions
• Reviews and adjudicates claims and/or non-medical appeals
• Determines whether to return, deny or pay claims following organizational policies and procedures

Claims Customer Service Advocate I

• 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
• 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 (written, telephone) regarding requested services to health care providers and members
• Performs medical or behavioral review/authorization process
• Ensures coverage for appropriate services within benefit and medical necessity guidelines
• Identifies and makes referrals to appropriate staff

RN Case Management Coordinator

Manager

• Provides oversight/direction for all activities of a membership area/function
• Manages the administration, implementation, maintenance and day-to-day operations, procedures, and activities of assigned cost centers or areas
• Provides communication and dissemination of information to staff members
• Prepares, reviews, and submits various reports required by management
• Prepares, monitors, and analyzes expenditures
• Ensures overall operational compliance
• Works with marketing, underwriting, claims, fiscal services, medical review, and other internal/external customers
• Responds to more sensitive, complicated and/or escalated issues and inquiries from internal/external customers
• Selects, trains, develops, and guides staff
• Monitors department performance and productivity
• Performs quality control functions for work performed

Member Services Manager

Security Engineer

• Support the secure adoption of artificial intelligence across BlueCross BlueShield of South Carolina
• Translate AI risk, security, privacy, and compliance requirements into practical architecture patterns
• Review systems for potential improvements and present recommendations
• Establish application architecture direction for change sheets and project efforts
• Ensure business objectives are met using approved architecture principles
• Provide architectural guidance on assigned efforts
• Serve as a key decision maker for architectural decisions

Senior AI Security Architect

• 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

• Provides active care management, assessing service needs, developing and coordinating action plans in cooperation with members, monitoring services and implementing plans, including 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, including intensive assessment/evaluation
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans
• Ensures coverage for appropriate services within benefit and medical necessity guidelines
• Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, etc.)
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies

Case Management Coordinator – Renal/Nephrology

Auditor

• Assisting in the execution of financial, compliance, and operational audits including evaluation of internal controls.
• Auditing the activity of various departments and providers for compliance with plans, policies, and procedures prescribed by management.
• Reviewing assigned portions of audit programs, determining compliance with policies and procedures, recommending corrective action plans, and preparing/submitting reports on audit results.
• Conducting audits of financial, management, and administrative procedures of assigned divisions, providers, and departments.
• Interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices, and reviewing relevant documentation.
• Developing detailed reports on each audit conducted.
• Reporting findings and identifying recommendations to correct deficiencies and improve processes.
• Conducting testing of corrective actions identified.
• Conducting special audit studies for management.

Auditor I, Medicare

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

Medical Reviewer II

Software Engineer

• 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

E-learning Designer, Developer

• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in 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.

Claims Customer Service Advocate II

• Responsible for analysis, design, programming, and implementation of the most complex applications tasks and projects in the area.
• Devise feasible, logical procedures to resolve business problems through the use of computer resources.
• Design, code, test and debug the most complex application programs.
• Provide technical direction and support in the development and support of business systems software and procedures.
• Review and analyze systems, streamlining processes to ensure efficient, consistent use of all resources.
• Act as an internal consultant, advocate, mentor, and change agent providing expertise and technical guidance on complex projects.
• Ensure solutions are aligned with business and IT strategies and comply with the organization’s architectural standards.

Senior Developer – Cobol

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of 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, 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
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel

Auditor II

Accounting Manager

• Prepares various financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function.
• Ensures data is complete, accurate, and organized for processing.
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
• Completes moderately difficult research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds.
• Resolves routine questions and problems, referring complex issues to higher levels.
• Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
• Provides other support duties related to the accounting/finance function that may include monitoring financial systems, keying journal entries, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc.
• May assists less experienced accounting clerks as needed.
• Determines, prepares, and distributes correspondence regarding monies due or erroneously received.
• Issues refunds as appropriate.

Accounting Technician II

QA Engineer

• Prepares and reviews test data and test matrices for system changes
• Develops test matrices to accurately reflect changes and details expected outcome
• Executes test cases and evaluates test results for errors
• Reports problems through appropriate channels and suggests corrections for a successful implementation
• Utilizes internal and external software necessary to support testing and development of skills
• Researches and documents system problems and assists in their resolution
• Reviews and completes various daily reports to ensure system is performing as expected
• Prepares written reports and analysis, including recommendations pertaining to system functionality
• Utilizes internal and external applications for technical research of system issues
• Functions as a liaison between the production operations areas, other area testers and Information Systems to facilitate communications
• Assists customers and testers with issues that arise both in production and during testing