PGBA,

Summary Performs routine but varied clerical duties in accordance with standard procedures. This includes clerical duties such as photocopying, compiling records, filing, tabulating, posting information, distributing mail, screening, scanning, data element verification and document indexing. Applies knowledge of department policies and procedures and utilizes a general understanding of other departments' functions. Maintains records, prepares forms, verifies information and resolves routine problems. Ensures claims are processed in a timely manner. Description Logistics: PGBA – one of BlueCross BlueShield's South Carolina subsidiary companies Location: This position is full-time (40-hours/week) Monday-Friday from 8:00am-5:00pm in a typical office environment. This role is located on-site at 200 N Dozier Blvd, Florence, SC 29501. After successfully completing training, this position may transition to a fully remote work schedule based on performance and business needs. - Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. - SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. What You’ll Do: - Receives, opens, sorts and distributes incoming departmental mail or work requests. Checks workflow documents to ensure required information is available. Requests any missing documentation as needed. Scans all documents for storage in the electronic repository. Prepares correspondence or packages for internal/external mailing. - Screens and verifies information. Ensures proper and accurate processing flow of all paper claims and correspondence in accordance with department standards for quality and production, contract regulations, policies and guidelines. - Conducts data element verification of data elements for those that fail the mapping process prior to claims adjudication. Applies appropriate indexes as needed to claims and/or correspondence. - Maintains departmental logs, spreadsheets or databases. Effectively uses all available reference materials in performance of daily functions. - Keeps track of supply inventory and/or orders supplies as needed. To Qualify for This Position, You'll Need the Following: - Required Education: High School Diploma or equivalent - Required Skills and Abilities: - Strong organizational and analytical skills. - Good communication and organizational skills. - Detail-oriented. - Ability to handle confidential or sensitive information with discretion. We Prefer That You Have the Following: - Preferred Skills and Abilities: - Ability to accurately key 5000 ksph or 30 wpm. - Knowledgeable in word processing and spreadsheet applications. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for 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. 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.

Summary Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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 administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Responsible for entry level accounting activities relating to the maintenance of a complete and accurate general ledger and/or the resultant managerial reports and/or financial statements. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. You may be required to travel between buildings. This role is located at 4101 Percival Road, Columbia, SC 29229. Logistics: PGBA one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This is a full-time position, with a remote schedule**, working an 8-hr. shift (40-hours/week) Monday-Friday 7:30am – 5:00pm with primary location at 17 Technology Circle Columbia SC, Columbia, SC 29203. **Qualified, local candidates need apply. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). To comply with the McNamara-O'Hara Service Contract Act (SCA), employees must enroll in our health insurance even if they have other health insurance. Employees will receive supplemental pay for health insurance until they are enrolled in our health insurance, first of the month following 28 days after the hire date. What You’ll Do: - Reconciles assigned accounts. Initiates and/or processes general ledger, and/or journal entries into various accounts. Prepare spreadsheets and/or ensures that entries are entered into the accounting system. Assist coworkers in preparation and/or/or review of daily activity, monthly, quarterly and/or annual filings as required by regulatory agencies and/or internal requirements, as well as entries made to various systems. - Prepares reports for financial analysis, forecasting, budgeting, trending, and/or results analysis to ensure transactions in the ledger tie to statistical files and/or various financial reports. Performs analysis of financial data to identify problem areas and/or report to management. - Maintains accurate general ledger (G/L) accounts. This includes performing monthly, weekly and/or daily reconciliations. - May assist with special projects as assigned by the manager to include coordination between areas, allocation of resources, formulating solutions to problems, providing timely feedback to the manager and/or developing and/or implementing job procedures/controls in accordance with policies. To Qualify for This Position, You'll Need the Following: - Required Education: Bachelor's in a job-related field with 24 semester hours in accounting. (Anyone hired prior to August 1, 2008 in an accounting position only requires 21 semester hours of accounting.) - Required Skills and Abilities: Knowledge of fundamental accounting concepts, practices and procedures. Good communication, organizational, customer service, and analytical skills. Ability to work independently. Ability to handle confidential or sensitive information with discretion. - Required Software and Tools: Microsoft Office. Ability to use data retrieval applications. We Prefer That You Have the Following: - Preferred Software: Strong MS Excel skills with ability to write queries using database software. - We prefer that you have 1+ years of accounting experience. Work Environment: Typical office environment. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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. 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.

Summary Join our team serving active and retired US military members and their covered family members. We strive to ensure that these dedicated individuals and their loved ones receive high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines. As part of our expanding team of medical reviewers, you will evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. In addition to being able to serve those who protect our country, you won’t have the physical stress of working in a direct care setting and you will have nights, weekends, and holidays off to spend with those you love. For those wanting to grow their career with us, we offer tuition reimbursement, skills training classes, an aspiring leaders’ program, and promotional opportunities throughout our family of companies. In these uncertain times, we are a solid company who has served individuals, businesses, associations, and the US government for over 70 years. Our leadership is committed to ensuring that we will be serving our customers for another 70 years. Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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 administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Logistics: PGBA - one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: This is an onsite position located at 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575. The hours are 8:00am - 5pm, Monday through Friday. This position will be remote after 6 months of training. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. What You Will Do: - May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made. - Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. - Participates in quality control activities in support of the corporate and team-based objectives. Participates in all Required Licenses and Certificates. To Qualify for This Position, You Will Need: - Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. - Required Experience: 2 years clinical experience. - Required Skills and Abilities: Working knowledge of word processing software. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to remain in a stationary position and operate a computer. - Required Software and Tools: Microsoft Office. - Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. ​ What We Prefer: - Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing. - Preferred Skills and Abilities: Working knowledge of spreadsheet and database software. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. - Preferred Software and Others Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software. - Preferred Licenses and Certificates: 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). Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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 a recruiter to verify resume specifics and salary requirements. 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.

Summary 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 administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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 administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Responsible for entry level accounting activities relating to the maintenance of a complete and accurate general ledger and/or the resultant managerial reports and/or financial statements. Logistics: PGBA one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full time and can be worked remotely (40 hours/week) Monday-Friday from 8:00am-4:30pm. **Due to some occasional needs to be on-site at 17 Technology Circle, Columbia, SC 29203, qualified, local candidates are encouraged to apply. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). To comply with the McNamara-O'Hara Service Contract Act (SCA), employees must enroll in our health insurance even if they have other health insurance. Employees will receive supplemental pay for health insurance until they are enrolled in our health insurance, first of the month following 28 days after the hire date. What You’ll Do: - Reconciles assigned accounts. Initiates and/or processes general ledger, and/or journal entries into various accounts. Prepare spreadsheets and/or ensures that entries are entered into the accounting system. Assist coworkers in preparation and/or/or review of daily activity, monthly, quarterly and/or annual filings as required by regulatory agencies and/or internal requirements, as well as entries made to various systems. - Prepares reports for financial analysis, forecasting, budgeting, trending, and/or results analysis to ensure transactions in the ledger tie to statistical files and/or various financial reports. Performs analysis of financial data to identify problem areas and/or report to management. - Maintains accurate general ledger (G/L) accounts. This includes performing monthly, weekly and/or daily reconciliations. - May assist with special projects as assigned by the manager to include coordination between areas, allocation of resources, formulating solutions to problems, providing timely feedback to the manager and/or developing and/or implementing job procedures/controls in accordance with policies. To Qualify for This Position, You'll Need the Following: - Required Education: Bachelor's in a job-related field with 24 semester hours in accounting. (Anyone hired prior to August 1, 2008 in an accounting position only requires 21 semester hours of accounting.) - Required Skills and Abilities: Knowledge of fundamental accounting concepts, practices and procedures. Good communication, organizational, customer service, and analytical skills. Ability to work independently. Ability to handle confidential or sensitive information with discretion. - Required Software and Tools: Microsoft Office. Ability to use data retrieval applications. We Prefer That You Have the Following: - Preferred Software: Strong MS Excel skills with ability to write queries using database software. - We prefer that you have 1+ years of accounting experience. Work Environment: Typical office environment. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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. 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.

Role Description Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Position Purpose: - Performs medical claim reviews and makes a reasonable charge payment determination. - Monitors process's timeliness in accordance with contractor standards. - Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. - Utilizes allocated resources to back up review determination. - Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. - May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. - Performs screenings/assessments and determines risk via telephone. - Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. - Provides education to members and their families/caregivers. - Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. - Conducts research necessary to make thorough/accurate basis for each determination made. - Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. - Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. - Participates in quality control activities in support of the corporate and team-based objectives. - Participates in all Required Licenses and Certificates. Qualifications - Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. - 2 years clinical experience. - Working knowledge of word processing software. - Good judgment skills. - Demonstrated customer service and organizational skills. - Demonstrated proficiency in spelling, punctuation, and grammar skills. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Ability to remain in a stationary position and operate a computer. Requirements - Microsoft Office. - Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. 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.

This position involves performing medical reviews and utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Performs medical claim reviews and makes reasonable charge payment determinations. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner. May conduct high dollar forecasting research and formulate overall patient health summaries. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures thorough documentation of each determination. Conducts necessary research to make thorough/accurate basis for each determination. Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. Participates in quality control activities in support of corporate and team-based objectives. Participates in all required licenses and certificates.