BlueCross BlueShield of South Carolina

Customer Support

• Ensure effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk-in inquiries.
• Accurately documents inquiries.
• Initiate or process adjustments or performs other research as needed to resolve inquiries.
• Coordinates with other departments to resolve problems.
• Responds to, research and/or assists with priority inquiries and special projects as required by management.
• Provide feedback to management regarding customer problems, questions, and needs.
• Maintains accurate records on complaints and/or other customer comments and makes recommendations for changes to management.
• Follows through on complaints until resolved or reports to management as needed.
• Maintain basic knowledge of quality work instructions and company policies.
• Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations.
• Maintains all departmental productivity, quality, and timeliness standards.
• Identify and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.

Customer Service Advocate I

Auditor

• Responsible for providing a full range of financial, compliance, and operational audits, business advisory, and consultation services
• Conduct 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
• Identify, document, and evaluate business risks
• Develop written audit programs
• Conduct testing and analysis of existing controls to determine adequacy and effectiveness
• Prepare written work papers to document testing results and conclusions reached
• Document issues, the causes of those issues, and their effects on the process/function and the corporation
• Serve as Lead Auditor on more complex audit assignments
• Draft recommendations to limit risks and improve processes, functions, and activities
• Write audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations
• Collect and analyze data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies
• Conduct testing of corrective actions as identified
• Develop detailed reports on each audit conducted

Auditor III

Claims Specialist

• Independently investigates, evaluates, and negotiates the resolution of assigned claims
• Conduct investigations of assigned claims in adherence with corporate timeliness and quality performance standards
• Manage caseload to ensure proactive disability, medical management and timely response to treatment recommendations
• 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
• Direct litigation process and work with attorneys to establish defense strategy and case legal budget
• Negotiate settlements directly with claimants or opposing counsel.
• Evaluate specials, damages, and/or extent of disability and negotiate settlements with individuals and/or attorneys.

Senior Claims Adjuster – Workers Compensation

Operations

• Analyzes data that has a vital impact on the success of the operation, program or project used for developing operating strategies
• Develops, maintains and reviews processes, procedures, policies and forms for the department
• Identifies patterns and trends in data for business decisions by department or division leadership
• Prepares materials which help explain findings such as reports, charts, visual aids, etc.
• Monitors departmental methods to ensure compliance with internal measures and contract/business requirements
• Reviews items directed to management
• Advises and keeps management apprised of any potential issues or items that need to be addressed
• Recommends a response or solution to any issues identified or outstanding
• Assists management with complex reviews such as analysis of expenditures that would help determine if process improvements, projects, or implementations are within projections
• Provides periodic/consistent information to management impacted by assigned projects
• Manage/relay project status, purpose, scope and timing
• Serve as liaison between the division or department and other areas on management reports, including reports concerning workload statistics
• Attends and participates in teleconferences and meetings with customers
• May also serve as liaison between the area and the contractor regarding any discrepancies found in reports
• Functions as a project leader on work teams
• Assists service areas with resolving compliance issues or questions
• Identify opportunities for improvement and areas/issues that can be addressed with educational initiatives
• Trains staff on new initiatives
• Identify and research discrepancies and questions related to data input based on reports
• Monitors reports to assess the impact of performance on key measures

Senior Operations Analyst

Medical Reviewer

• Perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or 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.
• Monitor process's timeliness in accordance with contractor standards.
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilize allocated resources to back up review determination.
• Review interdepartmental requests and medical information in a timely/effective manner to complete utilization process.
• Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Perform screenings/assessments and determine risk via telephone.
• Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provide education to members and their families/caregivers.
• Review first level appeal and ensure utilization or claim review provides thorough documentation of each determination and basis for each.
• Conduct research necessary to make thorough/accurate basis for each determination made.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participate in quality control activities in support of the corporate and team-based objectives.

Medical Reviewer I

• Audit and authorize reimbursement of specific 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 Auditor, Stoploss Claim

Medical Director

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a lead resource to providers and internal staff on issues concerning medical policies
• Heavily involved in policy generation, includes the development of new policy and revision of old policy
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

Chief Medical Officer – Medicare Policy

• Ensure effective customer relations by responding accurately, timely, and courteously to inquiries
• Handle non-routine inquiries which may require adaptation of response or extensive research
• Identify incorrectly processed claims and processes adjustments according to department guidelines
• Examine and process claims and/or non-medical appeals according to business/contract regulations
• Enter claims into the claim system after verification of correct coding
• Ensure claims are processing according to established quality and production standards
• Identify and report potential fraud and abuse situations

Claims Customer Service Advocate II

• 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, 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 and 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 II – Prior-Auth A/B MAC

Manager

• Responsible for the management of assigned claims operation(s)
• Ensure investigation and adjudication of claims meet performance standards and objectives
• Develop and maintain effective working relationships with business partners
• Responsible for the development of claims staff, vendors, and contractors
• Complete requests for proposal, bids, and due diligence on potential new jurisdictions
• Assist claims senior management team in achieving departmental and corporate strategies and goals

Manager, P & C Claims – Workers Compensation, General Liability

Administration

• Provides supervision and direction of the statistical reporting function and data analysis
• Monitors adherence to statistical reporting requirements
• Updates systems as necessary
• Sets and maintains general direction/focus of statistical reporting function
• Perform analysis and reporting including performing clinical trend analysis
• Develop reports through various data reporting tools
• Develop data driven solutions to improve outcomes
• Collaborate with other areas to reduce expense through data analysis
• Serve as internal subject matter expert and point of contact for query/design for clinical analysis
• Identifies data analysis needs based on customer
• Supervises staff including directing work, addressing performance, and providing training
• Review work and coaches subordinates

Clinical Reporting Supervisor

• Conducts audits of the financial, management, and administrative procedures of assigned divisions, providers, departments, and various lines of businesses throughout the organization to ensure that procedures are in compliance.
• Audits include interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices to determine effectiveness, and reviewing relevant documentation to support findings.
• 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.
• Conducts testing of corrective actions as identified.
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud.
• Prepares reports of finding 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 I, Medicare

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, and/or individual sales opportunities and works with groups, agents, 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 II

Account Manager

• Serves as the internal day-to-day client account manager
• Works with Consultants, Client Advocates, NA Operations and Support, Reporting Medical Management, Product Development, etc.
• Participates in the implementation of new clients
• Assists in the assessment of client-specific benefits to determine set up in the Group Library
• Monitors key deliverable dates related to marketing
• Trains clients and consultants on E bill
• Handles escalated or system problems identified by the Account Advocates
• Assures quality including accuracy of SBCs, Benefit Booklets and other client/member facing materials

Client Relationship Manager II

Consultant

• Assess for needs related to a member’s chronic condition, clinical risk and readiness for change via company needs questionnaire
• Based on the needs assessment, complete and coordinate action plans in cooperation with members, then implement plans to include member goals
• Provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to elicit behavior change and increase member program engagement
• Participates in patient education with members and providers regarding the member’s condition and available benefit plans
• Serves as member advocate through continued communication and education
• Promotes enrollment in health and chronic condition management programs
• Provides appropriate communications (written, telephone) regarding member conditions to both health care providers and members
• Participates in data collection/input into system for clinical information flow
• 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 network status of all service providers to educate members on care they may receive related to their chronic condition(s)
• Assists members with referrals to appropriate internal support areas to ensure proper processing of authorized or unauthorized services, as needed