BlueCross BlueShield of South Carolina

Product Designer

• Design user-friendly, effective, and engaging interfaces for mobile, tablet, and desktop applications
• Rapidly prototype and iterate on multiple design solutions
• Create user interface design artifacts describing the intended user experience
• Identify user needs and elicit user feedback
• Conduct user research activities and task flow analysis
• Synthesize research findings into recommendations and actionable results
• Share user data, insights, and best practices with the team
• Test and refine design decisions using user feedback and analytics
• Collaborate across business and application development teams
• Advocate for users and understand how audiences interact with applications
• Evangelize user experience best practices
• Collaborate with customers and internal team members to validate conceptual designs
• Provide support and documentation to maintain application usability integrity
• Serve as a subject matter expert and establish standards, best practices, and processes
• Stay current on user-centered design practices, innovations, trends, and methodologies
• Work closely with the Digital Implementation Lead and Digital Experience team to translate customer needs, business goals, and product strategy into digital solutions
• Participate in projects end to end, including research, testing, concept development, prototyping, UI copywriting, developer support, and UI standards compliance
• Share knowledge with team members, elevate UX maturity, and participate in bringing AI tools into the workflow
• Design primarily for the health insurance portal and app used by members across the country

Senior Product Designer

Content Writer

• Create reports according to user information and specifications
• Maintain and revise programming logic for existing routine reports to ensure timely and accurate data
• Analyze current reporting methodologies
• Create and maintain computer- and web-based systems for data retrieval
• Generate routine internal and external reports daily, monthly, quarterly, and annually
• Interview customers to obtain criteria for requested data
• Add and update programming logic according to customer specifications and requirements
• Assist with system testing and provide technical support
• Assist with departmental training issues
• Participate on project teams to develop, maintain, and implement new processes, applications, policies, and forms

Senior Database Report Writer, Analyst

Analyst

• Research complex appeal and retrospective review requests, including pre-pay and post-payment appeals
• Conduct clinical reviews or benefit analyses to determine whether services meet medical necessity guidelines
• Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations and standards
• Research member and provider service appeals using clinical documentation, contractual requirements, governing agency requirements, policies, and procedures
• Apply policies, procedures, clinical information, benefit provisions, and policy provisions to determine pertinent issues and precedence
• Maintain confidentiality of protected health information
• Perform special projects, including clinical information reviews to identify quality-of-care issues

Appeals Analyst

General

• Research requests, enter appropriate data to identify case specifics, and build appeals cases in the system
• Log requests to the appropriate functional area
• Generate letters, assemble files, order records, and obtain additional information as directed
• Ensure quality control of all appeals in the appeals system
• Pend documents to be saved electronically
• Prepare case files for review and/or further routing
• Complete training before transitioning to the hybrid work arrangement

Appeals Coordinator

Care Coordinator

• Review and evaluate medical or behavioral eligibility, benefits, and clinical criteria for service requests
• Apply clinical expertise, administrative policies, and established clinical criteria to utilization management decisions
• Assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and required services
• Promote quality and cost-effective outcomes using available resources
• Perform medical or behavioral review and authorization processes
• Ensure coverage for appropriate services within benefit and medical necessity guidelines
• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other appropriate staff
• Collect and input data for clinical information flow and claims adjudication
• Maintain compliance with applicable legislation and regulatory guidelines
• Provide discharge planning and assess service needs with providers and facilities
• Evaluate care-plan outcomes, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions
• Document clinical information supporting medical necessity criteria and contract benefits
• Collaborate with Care Management and other areas to execute care management processes timely
• Manage assigned members and authorizations through appropriate communication
• Communicate with healthcare providers and members by phone and in writing
• Participate in direct intervention and patient education regarding healthcare delivery systems, networks, and benefit plans
• Identify, initiate, and participate in on-site reviews when appropriate
• Promote enrollment in care management and health/disease management programs
• Maintain current knowledge of contracts and provider network status
• Assist with claims information, discussion, and resolution; refer issues to internal support areas

RN Managed Care Coordinator II – UM

• Research complex appeal and retrospective review requests, including pre-pay and post-payment appeals
• Conduct clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
• Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations or standards
• Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
• Apply policies, procedures, clinical information, benefit provisions, and precedence to appeal and retrospective reviews
• Conduct special projects, including reviewing clinical information to identify quality-of-care issues
• Complete approximately 8–12 weeks of training before beginning the regular shift

Analyst, Appeals

Customer Support

• Provide prompt, accurate, thorough, and courteous responses to customer inquiries
• Respond to telephone, written, web, or walk-in inquiries and accurately document them
• Initiate or process adjustments and conduct research to resolve inquiries
• Coordinate with other departments to resolve problems
• Respond to, research, and assist with priority inquiries and special projects
• Provide management with feedback regarding customer problems, questions, and needs
• Maintain accurate records of complaints and customer comments and recommend changes to management
• Follow through on complaints until resolved or report them to management as needed
• Maintain knowledge of quality work instructions and company policies
• Recommend process improvements based on daily operations
• Maintain departmental productivity, quality, and timeliness standards
• Identify and report or refer suspected fraudulent activities and system errors

Customer Service Advocate, I

• Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals
• Perform clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
• Document appeal or retrospective review bases accurately, timely, and in accordance with regulations or standards
• Research service appeals by members and providers using clinical documentation, contractual requirements, governing agencies, policies, and procedures
• Apply confidentiality regulations regarding protected health information
• Define and determine precedence of pertinent issues when applying policies, procedures, clinical information, and benefit or policy provisions
• Perform special projects, including reviewing clinical information to identify quality-of-care issues
• Complete training lasting approximately 8 to 12 weeks
• Work Monday through Friday, 40 hours per week, in an 8-hour shift within business hours; after training, shifts may begin as early as 6:00 a.m. Eastern Time

Solutions Engineer

• Work closely with Regional Sales/Account Management Directors to implement plans and strategies with 13 Blue partners across the nation
• Build brand identity by representing National Alliance at national conventions and fairs, with opportunities for speaking engagements
• Expand partner relationships and serve as an internal liaison to key support areas
• Build metrics to measure successes and gaps in partner plans and help align team resources
• Communicate with Partner Plans to manage mutual goals and objectives
• Assess and implement resource and training needs for Partner Plan staff
• Establish and maintain a visible field presence with staff and plans
• Monitor marketplace trends, competitors, BlueCross BlueShield Association initiatives, and product design
• Share marketplace data with senior management and Partner Plans
• Manage Partner Plan distribution-channel relationships, including legal, policy, procedure, and issue resolution matters
• Coordinate Partner Plan meetings, including executive oversight, steering, quarterly, and semiannual account-management meetings
• Communicate with staff and management regarding information needed to achieve goals
• Monitor performance metrics and distribute them to Partner Plans
• Complete reporting requirements within specified time periods

Partner Solutions Manager

Auditor

• Coordinate and complete audit reviews
• Review audit work papers and reports completed by department staff
• Distribute reports to management
• Coordinate auditors' assignments
• Mentor and coach department staff
• Assist the department manager with workflow direction for risk management activities and special projects
• Plan and execute audits in accordance with professional auditing standards
• Perform or support audits focused on operational controls, asset safeguarding, and compliance
• Serve as in-charge auditor for complex audit reviews and/or cost reports
• Review account reconciliations performed by financial areas
• Analyze key processes, systems, and controls to determine effectiveness
• Communicate audit status and results to management, discuss deficiencies, and recommend corrective actions
• Prepare formal written work papers and reports documenting audit work and conclusions
• Assess subordinate auditors' desk reviews and provide on-the-job training
• Ensure audits comply with GAAP, GAAS, and Government Auditing Standards
• Coordinate assignments for timely completion within budget and departmental goals
• Direct day-to-day efforts of assigned audit staff through planning, training, leadership, and guidance
• Assist with developing and revising work instructions, forms, and procedures
• Maintain knowledge of applicable laws, regulations, and procedures through self-study, on-the-job training, seminars, and formal training programs
• Communicate with internal and external areas to ensure efficient task completion

Lead Medicare Cost Reporting Auditor

Sales

• Lead corporate distribution systems, general agents, brokers, and other market support personnel
• Plan product development, marketing services, production, and profitability across assigned states or regions
• Engage regularly in outside sales
• Solicit new distribution outlets for Companion Life's products
• Motivate general agents and brokers through visits and seminars
• Formulate, advise on, and implement policies to enhance production profitability and service standards
• Develop marketing and sales themes, promotions, and sales materials
• Monitor loss ratios and persistency and implement corrective actions
• Develop or enhance group products and recommend pricing, product design, filing, direct mail, and compliance requirements
• Manage marketing, sales, renewal, and servicing of Companion Life's products from a field office environment

Director, Ancillary Sales & Marketing

Software Engineer

• Guide and support a team of application developers within an assigned application area
• Provide day-to-day technical direction and help developers break down and prioritize work
• Monitor progress and ensure solutions are well-designed, high quality, and delivered on time
• Adjust workload distribution and reassign development resources to support shifting priorities and resolve bottlenecks
• Produce deliverables related to assigned projects
• Perform analysis, design, programming, and implementation of systems and procedures for complex business or scientific problems
• Evaluate interrelationships in programming areas and assess impacts of program changes
• Apply conversions and enhancements to business systems
• Lead or provide expertise on assigned projects
• Work with customers, business analysts, and team members to understand requirements and design quality technical solutions
• Ensure solutions align with business and IT strategies and architectural standards
• Provide post-implementation support and system enhancements
• Test modified and designed programs, create test files and data, verify logic, debug, and write documentation
• Design, develop, code, implement, maintain, and support complex application software throughout the full systems life cycle
• Devise new data sources, approaches, and techniques
• Provide guidance to lower-level programmers and analysts
• Act as an internal consultant on complex projects
• Determine and resolve problems with systems analysts, programmers, and systems users

Developer IV – Technical Team Lead

Medical Reviewer

• Act as team lead for specialty programs, medical review, utilization management, and case management areas
• Provide assistance and support to the unit supervisor/manager
• Give direction, guidance, and training to staff
• Ensure appropriate levels of healthcare services are provided
• Function as a team leader/senior-level Medical Reviewer
• Maintain working knowledge of unit functions, department inner workings, and workflow
• Serve as a resource for staff and external entities by troubleshooting and resolving issues
• Keep the manager informed of problems and issues requiring resolution
• Assist management with monitoring workflow and workloads
• Reassign work and redirect work intake sources to balance workloads and meet timelines
• Monitor reporting and address aging issues
• Participate in departmental quality reviews and ensure adherence to the quality plan
• Give and receive feedback regarding medical review decision-making and technical claims processing issues
• Ensure quality work instructions, forms, and documents are developed or revised as needed
• Provide quality service and communicate effectively with internal and external customers
• Obtain information from internal departments, providers, government, and private agencies to resolve discrepancies and problems
• Participate in compliance initiatives, directed activities, and special projects as requested by management
• Work Monday-Friday, 40 hours per week, during 8:00am-4:30pm or 8:30am-5:00pm schedules

Senior Medical Reviewer

• Develop, maintain, and execute complex database programs for extracting and presenting data for standard and ad hoc reporting
• Create supporting documentation outlining procedures within scope of responsibility
• Develop complex sampling designs and/or execution methodology for sample selection
• Develop difficult statistical analyses using standard reporting, ad hoc reporting, and data mining tools
• Provide sophisticated data interpretation, compilation, and verification to guide departmental efforts
• Prepare charts, illustrations, graphics, and narrative reports to identify and explain patterns and trends
• Participate in writing articles suitable for internal/external publication
• Assist in developing project plans and system life cycle maintenance
• Perform quality checks on relational database tables
• Help develop focused end-user applications
• Participate in developing change requests and testing plans for changes to relational database tables
• Research new data sources and provide written and/or verbal feedback to management

Statistical Programming III Analyst

Data Analyst

• Support Medicare Advantage Operations by providing scheduled and ad hoc reports
• Collaborate with Claims, Membership, Medical Management, Sales & Marketing, Change Management, and the STARS team
• Review, extract, and analyze data for procedures, processes, and requirements
• Provide reports to identify problematic areas and support modification or elimination of operational issues
• Assist with complex analysis and sophisticated data compilation, verification, and interpretation
• Perform focused analyses as needed
• Create data search programs to identify pertinent data for system or operational enhancements and changes
• Document reporting procedures so staff can independently run ad hoc reports
• Design, code, and maintain complex database programs for data extraction and analysis supporting financial and operational decisions
• Run queries to pull data from DB2 relational databases on the host mainframe to generate reports for Medicare Advantage Operations

Senior Product Designer

Senior Database Report Writer, Analyst

Appeals Analyst

Appeals Coordinator

RN Managed Care Coordinator II – UM

Analyst, Appeals

Customer Service Advocate, I

Analyst, Appeals

Partner Solutions Manager

Lead Medicare Cost Reporting Auditor

Director, Ancillary Sales & Marketing

Developer IV – Technical Team Lead

Senior Medical Reviewer

Statistical Programming III Analyst

Data Analyst II