Develops comprehensive reports and analyzes data in order to identify patterns and trends. Assists in creating materials that aid in illustrating analytical/data findings. Identifies opportunities for improvement that can be addressed with educational initiatives. Description Uses multiple software platforms to produce reports in accordance with work requests, internal in

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Description Performs medical claim reviews for one or more of the follo

Provides support to the Workers' Compensation department. Establishes and process claims in compliance with all applicable federal and state laws and policies, and departmental standards. Manages all the regulatory reporting for multiple jurisdictions. Responsible for responding to customer inquiries, which may be non routine and require deviation from standard screens, s

Assists with health management activities/programs for BlueCross BlueShield of South Carolina (BCBSSC) and/or Medicare Advantage members. Description 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 identifica

Screen, code and key claims in claims system. Ensure claims are processed in a timely manner. Description Screen, code and key claims to ensure proper and accurate adjudication of claims in accordance with departmental standards for quality and production, contract regulations, policies and guidelines. Correct keying errors as noted by system edits. Accurately use medical

Maintains actuarial reporting systems, analyzes actuarial reports, summarizes reports, and provides recommendations. Description Compiles monthly and quarterly actuarial reports. Extracts mainframe data into spreadsheet form. Performs profitability analysis and determination of appropriate level and rates for various lines of business. Reviews rating bureau changes, makin

Responsible for effective and efficient recruitment activities. Maintains active requisition load for high volume, repetitive jobs, campus recruiting, internships, and/or entry level professional roles. Fills open positions while remaining compliant with corporate policies and procedures and applicable government activities. Recognizes and utilizes recruitment practices t

Provides care management services to more than 2 million members in South Carolina and nationally. Administers complex, high touch concierge case management for members identified into specialized programs such as high risk maternity, NICU, ESRD, Palliative Care Behavioral Health. Identifies risks and provides outreach services to facilitate the coordination of healthcare

Responsible for leading accreditation compliance activities to include interpretation of the standards, monitoring of multiple areas' compliance, providing guidance to management and associates on compliance issues. Provides HEDIS support for multiple departments. Develops special coding plan for HEDIS and Accreditation initiatives. Assists in the oversight and management

Provides direct physician support. Oversees health and disease management programs. Oversees utilization management case evaluation for medical necessity. Reviews and communicates medical decisions. Interacts with network physician providers to resolve case by case complaints. Oversees medical aspects of vendor relationships. Assists in developing medical policy. Descript

Responsible for the successful marketing (sales, renewals, and/or service) of group and/or individual accounts for products as defined by production quotas within assigned territory. Customarily and regularly engaged in outside sales. Description Develops and executes marketing plans for new sales and/or retention of existing accounts within assigned territory. Prepares a

Responsible for the accurate and timely processing of claims. Description Researches and processes claims according to business regulation, internal standards and processing guidelines. Verifies the coding of procedure and diagnosis codes. Resolves system edits, audits and claims errors through research and use of approved references and investigative sources. Coordinates

Prepares and revises automated cost report data files to incorporate audit adjustments and to ensure that cost reports meet all requirements for acceptance. Processes original filing and settlement cost reports. Description Completes revisions of cost report data files incorporating the audit adjustments. Prepares the formal audit adjustment report, ensuring that all adju

Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Performs research as needed to resolve inquiries. Description 65% Ensures effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk in inquiries. Accurately documents inquiries. 15% Initiates or processes adjustments or performs ot

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrator