Palmetto GBA

Role Description 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. Logistics: - Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies. - This is a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday. It may be necessary, given the business need, to work occasional overtime. - This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. What You'll Do: - 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 and 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/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. Qualifications - Required Education: Associate's in a job-related field. - Degree Equivalency: Graduate of Accredited School of Nursing. - Required Work Experience: 2 years clinical experience. - Required Skills and Abilities: - Working knowledge of word processing software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service and organizational skills. - Demonstrated oral and written communication skills. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Required Software and Tools: Microsoft Office. - Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Benefits - Subsidized health plans, dental and vision coverage. - 401k retirement savings plan with company match. - Life Insurance. - Paid Time Off (PTO). - On-site cafeterias and fitness centers in major locations. - Education Assistance. - Service Recognition. - National discounts to movies, theaters, zoos, theme parks and more.

Role Description Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. This is a full-time position (40 hours per week), Monday through Friday, and is fully remote (Work from Home). This opportunity is open exclusively to candidates currently residing in South Carolina or Georgia. What You Will Do: - Functions as team leader/senior-level Medical Reviewer. - Provides leadership/guidance/direction/training to staff. - Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow. - Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving. - Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance work loads), reporting, and addressing aging issues. - Participates in departmental quality reviews. - Follows process to ensure quality plan is adhered to and communicated to all parties. - Gives/receives feedback regarding medical review decision making and technical claims processing issues. - Ensures that quality work instructions/forms/documents are developed/revised as needed. - Provides quality service and communicates effectively with external/internal customers in response to inquiries. - Obtains information from internal departments, providers, government, AND/OR private agencies, etc. to resolve discrepancies/problems. - Participates in compliance initiatives and other directed activities. - Participates/oversees special projects as requested by management. Qualifications - Associate Degree - Nursing, OR Graduate of Accredited School of Nursing. - Four years clinical, OR Two years clinical and two years medical review/utilization review, OR Combination of health plan, clinical, and business experience totaling four years. - Working knowledge of managed care and various forms of health care delivery systems. - Strong clinical experience to include home health, rehabilitation, AND/OR broad medical surgical experience. - Knowledge of specific criteria/protocol sets and the use of the same. - Working knowledge of word processing and spreadsheet software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service, organizational, and presentation skills. - Demonstrated proficiency in spelling, punctuation, and grammar skills. - Demonstrated oral and written communication skills. - Ability to persuade, negotiate, OR influence others. - Analytical OR critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Ability to lead/direct/motivate others. - Microsoft Office. - RN, active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Requirements - Rail Road Benefits experience. Benefits - 401(k) retirement savings plan with company match. - Subsidized health plans and free vision coverage. - Life insurance. - Paid annual leave – the longer you work here, the more you earn. - Nine paid holidays. - On-site cafeterias and fitness centers in major locations. - Wellness programs and healthy lifestyle premium discount. - Tuition assistance. - Service recognition. - Incentive Plan. - Merit Plan. - Continuing education funds for additional certifications and certification renewal.

Role Description 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. Location: This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama. What You'll Do: - Perform 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 - Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. - Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. - Monitor process’s timeliness in accordance with contractor standards. - Document medical rationale to justify payment or denial of services and/or supplies. - Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. - Participate in quality control activities in support of the corporate and team-based objectives. - Provide guidance, direction, and input as needed to LPN team members. - Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. - Assist with special projects and specialty duties/responsibilities as assigned by management. Qualifications - Associate's in a job related field - Graduate of Accredited School of Nursing. - Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). - 2 years clinical experience. - Working knowledge of word processing software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service and organizational skills. - Demonstrated oral and written communication skills. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Microsoft Office. Benefits - 401(k) retirement savings plan with company match - Subsidized health plans, dental and vision coverage - Life insurance - Paid Time Off (PTO) - Nine paid holidays - On-site cafeterias and fitness centers in significant locations - Wellness programs and a healthy lifestyle premium discount - Tuition assistance - Service Recognition Company Description We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

• 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 and 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/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.

• Performs medical review 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. • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. • Determines medical necessity and 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/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.

• 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 and 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/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.

Summary Responsible for the coordination and completion of the audit reviews, reviewing audit work papers and reports completed by department staff, distributing reports to management, coordinating auditor’s assignments, mentoring and coaching department staff, and assisting the department manager with the direction of the workflow of various risk management activities and special projects. Description This a part time position working approximately 20-30 hours weekly. This is a remote position and the task can be performed at any location. What You'll Do: - Independently and objectively helps plan and execute audits in accordance with professional auditing standards. Performs or supports audits focused primarily on operational controls, asset safeguarding, and compliance with procedures, laws, and regulations. Functions as in-charge auditor of the most complex audit reviews and/or cost reports. May conduct reviews of account reconciliations performed by various financial areas. - Identifies and analyzes related key processes, systems, and controls to determine effectiveness. Communicates audit status and results to management, with emphasis on discussing deficiencies and recommending corrective actions. Prepares formal written work papers and reports, documenting audit work performed and expressing conclusion. - Assesses desk reviews performed by subordinate auditors to ensure that quality audit work is performed and on-the-job training is provided as necessary. Assists in ensuring that all assigned audits are completed and reviewed in accordance with Generally Accepted Accounting Principles, Generally Accepted Auditing Standards and, Government Auditing Standards. Coordinates the completion of these assignments in a manner which results in timely completion of all assignments in accordance with budget performance requirements as well as departmental interim goals. - Directs the day-to-day efforts of assigned audit staff by reviewing and planning assignments, training, and providing leadership and guidance. Assists in the development and revision of work instructions, forms, and procedures. - Broadens and maintains working knowledge of applicable laws, regulations, and procedures through self-study programs, on-the-job training, attending seminars and network association’s formal training programs. Communicates with internal and external areas as necessary to ensure efficient completion of assigned tasks. Required Education: Bachelor's in a job related field Required Work Experience: 7 years auditing or accounting experience with one-year leading audits. Required Skills and Abilities: Knowledge of the principles and practices of auditing. Ability to analyze and determine the applicability of financial data, to draw conclusions and make appropriate recommendations. Ability to gather information by examining records and documents and to interview individuals concerning those records. Strong interpersonal skills and the ability to work professionally with persons at all levels, and to maintain effective working relationships. Ability to communicate clearly and effectively in oral and written form. Ability to handle sensitive matters on a confidential basis. Knowledge of cost accounting standards and General Accepted Accounting Principles. Knowledge and use of auditing standards and statistical sampling techniques. Good planning and organization skills. Required Software and Tools: Microsoft Office. Preferred Licenses and Certificates: Certified Internal Auditor (CIA) or Certified Public Accountant (CPA) or Certified Information Systems Auditor (CISA) Work Environment: Typical office environment. Some travel between office buildings. Out of town travel may be required. Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits at the first of the month following 28 days of employment: - Subsidized health plans, dental and vision coverage - 401k retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - On-site cafeterias and fitness centers in major locations - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Salary Range: Range Minimum $30,227.50 Range Midpoint $49,040.50 Range Maximum $60,588.00 Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

• Evaluates the activities, performance and systems within a specific area for standards and workflow simplification. • Compiles data for analysis and prepares reports and presentations for management using applicable programming languages and/or software products. • Reviews system enhancements/upgrades to determine applicability of customer file modification requirements. • Facilitates timely and accurate updates to reference files based on customer requests. • Coordinates testing and debugging of new or modified software. • Creates test matrices and supporting documentation. • Develops and executes formal test plans to ensure delivery of quality software applications. • Monitors software implementations for exceptions and to verify that changes to the systems' operational process had the desired effect. • Identifies and documents systems problems and assists in their resolution. • Researches system problems and identifies potential solutions. • Investigates and diagnoses system problems, formulates solutions, initiates change sheets, defines business requirements and tests corrections. • Researches any questionable standard system or local component problematic situations to assure compliance and accuracy. • Under general direction, defines business requirements, tests, and leads small to moderate projects. • Assists management in performing business reviews by analyzing internal/external projects and changes. • Ensures changes do not have a negative impact on productivity and procedures. • Makes recommendations to improve productivity, cost effectiveness and timeliness. • Communicates with management and departmental personnel to document workflow procedures. • Assists in preparing verbal and written communication about business changes with management or other staff members. • Prepares written reports and analyses pertaining to testing results and related data, including recommendations for customers on improving operational workflows.

• Evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, 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 • Perform medical claim reviews and makes a reasonable charge payment determination • 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 • 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

Summary Responsible for providing a full range of financial, compliance, and operational audits, business advisory, and consultation services, investigations, internal controls, accountability, and use of resources. Description The Auditor position is a full-time (40 hours) remote position. This position has the ability to work from any US location. What You'll Do: - Conducts 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. Identifies, documents, and evaluates business risks. Develops written audit programs. Conducts testing and analysis of existing controls to determine adequacy and effectiveness. Prepares written work papers to document testing results and conclusions reached. Documents issues, the causes of those issues, and their effects on the process/function and the corporation. Serves as Lead Auditor on more complex audit assignments. - Drafts recommendations to limit risks and improve processes, functions and activities. Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions and recommendations. Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies. Conducts testing of corrective actions as identified. - 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. Examine and evaluate financial and information systems, recommending controls to ensure system reliability and data integrity. - Conducts special audit studies for management, such as those required to discover controls for prevention of fraud. Prepares reports of findings and recommendations for management. - Provides training to and assists or leads other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel. - Strives to expand knowledge of applicable laws, regulations, program instructions, and technology through self-study, corporate offerings, and formal training programs. What You'll Need: Required Education: Bachelor's in a job related field. Required Experience: 5 years auditing experience. Required Skills and Abilities: Knowledge of the principles and practices of auditing. Ability to analyze and determine the applicability of financial data, to draw conclusions and make appropriate recommendations. Ability to gather information by examining records and documents and to interview individuals concerning those records. Strong interpersonal skills and the ability to work professionally with persons at all levels, and to maintain effective working relationships. Ability to communicate clearly and effectively in oral and written form. Ability to handle sensitive matters on a confidential basis. Excellent analytical or critical thinking and problem solving capabilities. Required Software and Tools: Microsoft Office. Preferred Education: Bachelor's degree- any major Preferred Licenses and Certificates: Certified Internal Auditor (CIA), Certified Public Accountant (CPA), or Certified Information Systems Auditor (CISA) Work Environment: Typical office environment. Travel between office buildings and out of town may be required. Pay Range Information: Range Minimum  $62,289.00 Range Midpoint  $90,417.00 Range Maximum  $118,545.00 Pay Transparency Statement: Please note that this range represents the pay range for this and other positions that fall into this pay grade.  Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity. Equal Employment Opportunity Statement: BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.