BlueCross BlueShield of South Carolina

This role involves leading, marketing, recruiting, and motivating general agents and brokers to actively solicit new distribution outlets for the company's products. The representative will also be responsible for formulating policies, developing sales materials, monitoring performance metrics like loss ratios, and enhancing group products.

This role ensures adherence to Local Coverage Determination (LCD) contract instructions by developing and maintaining educational tools to help providers reduce non-covered service claims and lower the claims payment error rate. The coordinator will provide clinical expertise and judgment to develop and maintain LCDs, educate internal and external customers, and ensure coordination and compliance regarding coding and reimbursement guidelines.

The main duties involve auditing and authorizing reimbursement for specific medical stop loss claims while effectively mitigating client risk and providing excellent customer service. Responsibilities include analyzing and adjudicating claims, recognizing cost mitigation opportunities, and initiating investigations.

The role involves conducting internal and external audits covering financial, compliance, and operational aspects, including evaluating internal controls and identifying business risks across various corporate divisions and providers. Responsibilities also include drafting clear audit reports for executive management, documenting findings, recommending risk mitigation strategies, and testing corrective actions.

The role involves providing active care management, assessing member needs, developing and coordinating action plans, and monitoring service outcomes, including evaluating eligibility and medical necessity for requested services. Responsibilities also include providing telephonic support, member-centered coaching using motivational interviewing, and performing medical or behavioral review/authorization processes.

This role provides supervision and direction for the statistical reporting function and data analysis supporting clinical reporting, while maintaining high standards of integrity and confidentiality regarding member/beneficiary privacy. Key duties include monitoring reporting adherence, setting the function's direction, performing clinical trend analysis, developing data-driven solutions, and collaborating across areas to reduce expenses.

The Medical Director provides administrative oversight to the medical staff, analyzes utilization data, researches new medical procedures, and serves as a resource on medical policies for providers and internal staff. Key duties include supporting operations through case review, developing claim adjudication criteria, and educating the medical community on policy administration.

The RN Appeals Analyst will research complex appeal or retrospective review requests, including pre-pay and post-payment reviews, to determine if requested services meet medical necessity guidelines. This role involves documenting decisions accurately and timely in compliance with regulations, and performing special projects like reviewing clinical information for quality-of-care issues.

The Senior Stop Loss Underwriter is responsible for profitably underwriting employer stop-loss business across Managed Care Organizations, TPAs, brokers, hospitals, and BlueCross BlueShield partners. The role evaluates risk, applies financial discipline, and secures appropriate r...

The Customer Service Advocate I is responsible for providing prompt, accurate, and courteous responses to all customer inquiries via telephone, written, web, or walk-in methods. This role involves performing necessary research, accurately documenting interactions, coordinating with other departments to resolve issues, and maintaining accurate records of complaints.