BlueCross BlueShield of South Carolina

Medical Director

• Provide medical leadership and support on medical and regulatory matters
• Oversee physician review, utilization review, quality assurance, and case management
• Develop and implement medical policies and standards
• Evaluate new technologies and treatments
• Identify medical and pharmacy cost and utilization trends and recommend solutions
• Provide clinical oversight for behavioral health activities across utilization management, care coordination, quality, and population health for South Carolina Medicaid
• Align Healthy Blue’s behavioral health strategy with SCDHHS priorities and statewide goals
• Make defensible, evidence-based utilization decisions and review complex and high-cost cases
• Partner with program integrity teams to identify inappropriate utilization patterns
• Lead integrated behavioral health/medical models, suicide prevention, crisis response, and transitions-of-care strategies
• Advance health equity across South Carolina’s rural and urban regions
• Lead clinical teams and operations to improve compliance, efficiency, and communication
• Support Payment Integrity units by analyzing abuse patterns and recommending solutions
• Oversee quality improvement and health plan and medical program accreditations
• Develop quality initiatives and provide clinical support and network outreach
• Perform physician review for utilization management, appeals, and case management
• Research new or controversial medical procedures and technologies
• Educate staff, network providers, and the medical community on medical policy and program administration

Behavioral Health Medical Director

Customer Support

• Provide prompt, accurate, thorough, and courteous responses to complex customer inquiries
• Research and resolve non-routine inquiries requiring deviation from standard screens, scripts, and procedures
• Review and adjudicate complex or specialty claims and/or non-medical appeals
• Determine whether to return, deny, or pay claims according to organizational policies and procedures
• Review claims or appeals issues, complaints, and inquiries to determine whether desk procedures and guidelines were followed
• Research underlying causes and identify ways to prevent and correct them
• Identify and report potential fraud and abuse situations
• Examine and process claims and/or non-medical appeals according to business and contract regulations, internal standards, and examining guidelines
• Enter claims into the claims system after verifying procedure and diagnosis coding
• Ensure claims meet quality and production standards
• Provide feedback to management regarding customer issues and maintain accurate issue records
• Follow through on complaints until resolution or report them to management
• Maintain knowledge of procedures and policies
• Recommend process and policy improvements
• Assist in training claims customer service representatives

Claims Customer Service Advocate III

• Respond to customer inquiries by telephone, written communication, web, or walk-in interactions
• Research and resolve non-routine or complex inquiries requiring adaptation of standard screens, scripts, and procedures
• Review and adjudicate claims and/or non-medical appeals
• Determine whether to return, deny, or pay claims according to organizational policies and procedures
• Identify incorrectly processed claims and process adjustments and reprocessing actions
• Examine and process claims and non-medical appeals according to business and contract regulations, internal standards, and examining guidelines
• Enter claims into the claim system after verifying correct procedure and diagnosis coding
• Process claims according to established quality and production standards
• Escalate complex complaints and inquiries to a lead or manager
• Identify and report potential fraud and abuse situations

Claims Customer Service Advocate II

General

• Maintain records and process claims in medical review
• Process ingoing and outgoing mail and prepare work for nursing staff
• Troubleshoot claims before and after nurse review
• Monitor claim-processing timeliness and adjust incorrectly keyed claims
• Perform quality control of work processes
• Process claim denials and adjustment claims for pre-pay and post-pay departments
• Investigate and analyze adjustment claim history and denial records
• Prescreen records for review and maintain accurate claim records
• Communicate with providers and assist the provider service department with inquiries
• Generate educational correspondence to providers regarding denials
• Assist the manager with special projects
• Serve as clerical support for Palmetto GBA's medical review team

Technical Information Specialist

Case Coordinator

• Provide active care management and assess members’ service needs
• Develop, coordinate, monitor, and evaluate member-centered action plans
• Assess eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions
• Document clinical information supporting medical necessity and contract benefits
• Provide telephonic support for members with chronic conditions, high-risk pregnancy, and other at-risk conditions
• Deliver condition-specific education and member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment
• Educate and intervene directly with members and providers regarding health care delivery, networks, and benefit plans
• Identify, initiate, and participate in on-site reviews
• Advocate for members through continued communication and education
• Promote enrollment in care management and health and disease management programs
• Communicate requested-service information to health care providers and members in writing and by telephone
• Perform medical or behavioral review and authorization processes
• Ensure service coverage complies with benefit and medical necessity guidelines
• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care teams
• Collect and input clinical information for proper claims adjudication
• Comply with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations
• Maintain current knowledge of contracts and provider network status
• Assist with claims information, discussion, and resolution; refer issues to internal support areas

Case Management Coordinator, Maternity Focus

Software Engineer

• Perform all phases of application systems analysis and design
• Analyze systems specifications and develop applications supporting information systems processes
• Prepare detailed specifications for complex programs
• Design, code, test, debug, document, and maintain programs
• Formulate scope and objectives through research to develop or modify complex systems
• Ensure team members understand business requirements and that organizational standards and project timelines are met
• Provide expert system knowledge, perform research, attend meetings, and review documents
• Maintain and modify programs according to specifications
• Code, compile, and implement application software on time and within budget
• Evaluate interrelationships in the immediate programming area to assess the impact of program changes
• Test modified programs, create test files and data, verify logic, debug, and write documentation
• Analyze production systems, recommend enhancements, instruct production support teams, research customer issues, determine resolutions, and coordinate implementations
• Analyze and evaluate existing or proposed systems
• Develop functional designs, technical specifications, concept diagrams, workflow diagrams, and related data-processing procedures
• Document programs and procedures
• Work in a customer-focused, project-oriented programming environment
• Support a fast-paced, multiplatform environment that may require 24x7 response to technical business needs

Developer III

Medical Reviewer

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
• Make payment determinations based on clinical medical information and established criteria, protocols, or clinical guidelines
• Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
• Monitor process timeliness according to contractor standards
• Document medical rationale supporting payment or denial of services and supplies
• Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
• Participate in quality control activities supporting corporate and team objectives
• Provide guidance, direction, and input to LPN team members
• Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties assigned by management

Medical Reviewer II

Clerk

• Assist management in planning, coordinating, and assigning work across staff
• Train new staff and assist staff with proper processing methods
• Assemble and distribute electronic and hard copy claims to support staff
• Screen, code, and key claims to ensure proper and accurate adjudication
• Process edits and resolve errors through claims editing software
• Collect, sort, and deliver completed claims to the appropriate area
• Document errors and other important information throughout claims processing
• Assist support staff with questions throughout processing
• Work Monday-Friday, 8:00 AM to 5:00 PM, 40 hours per week

Lead Claims Clerk

• Process denials of claims
• Process adjustment claims for pre-pay and post-pay departments
• Investigate and analyze adjustment claim history and denial records
• Prescreen records for review and maintain accurate claims records
• Communicate with providers and assist the provider service department with inquiries
• Generate educational correspondence to providers regarding denials
• Perform quality control of work processes
• Assist the manager with special projects
• Maintain records and process claims in medical review
• Process incoming and outgoing mail and prepare work for nursing staff
• Troubleshoot claims before and after nurse review
• Monitor claims-processing timeliness and adjust incorrectly keyed claims