BlueCross BlueShield of South Carolina

Role Description We are currently hiring for an Appeals Specialist to join BlueCross BlueShield of South Carolina. In this role as Appeals Specialist, you will be required to perform non-medical reviews and process redetermination letters. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Logistics - CGS (cgsadmin.com) – one of BlueCross BlueShield's South Carolina subsidiary companies. - This position is onsite with work hours starting between 6:00 AM and 7:30 AM Central Time. - You will work an 8-hour shift schedule. - It may be necessary to work occasional overtime. - This role is fully remote or can sit onsite at 26 Century Blvd, Suite ST610 Nashville, TN 37214 United States of America. - As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. - Your coverage begins on the first day of the month following 28 days of full-time employment. What You’ll Do - Perform non-medical reviews and process redetermination letters ensuring timeliness and accuracy. - Prepare unit reports, analyze and interpret workload, and process issues utilizing various software tools. - Update letters and documents within the department when necessary. - Gather and prepare documentation for legal inquiries and administrative requests. Qualifications - High School Diploma or equivalent. - 2 years job related field experience. - Demonstrated proficiency in word processing and spreadsheet software. - Excellent organizational, customer service, and written and verbal communication skills. - Good judgment skills. - Proficiency in spelling, punctuation, and grammar skills. - Microsoft Office proficiency. Requirements - Experience in medical claims processing, appeals, or coding strongly preferred. - Medicare Part B experience preferred. - Strong computer proficiency, with the ability to navigate multiple systems and work across dual screens efficiently. - Intermediate-level Excel skills. - Experience creating letters and documents by reviewing appeals and extracting information with a high degree of accuracy; updates departmental documents as needed. 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.

• Oversee user experience (UX) design ideation, and iteration, while ensuring the team adheres to best practices • Provide strategic direction in the development of testing approaches, including strategy, participant recruitment, and leveraging vendors and/or technology in the process • Enable the UX design process through strategic evaluation, acquisition, and management of technology/tools • Provide project support, to include translating design into project requirements, effectively communicating business needs, managing deadlines and team deliverables, and supporting implementation • Oversee the development and deployment of digital content across platforms to ensure editorial consistency and adherence to brand and corporate digital guidelines • Partner with team members to develop, implement, and communicate digital governance practices • Responsible for member engagement strategy and omni-channel content development • Responsible for recruiting and hiring, coaching and mentoring, monitoring and evaluation, and addressing all disciplinary issues in a timely manner • Encourage staff in creating and maintaining a work environment with a high morale and employee satisfaction through support of professional development, training, career growth, and rewarding high performance • Conduct market and design research in support of digital strategy efforts • Monitor industry trends incorporate best practices into work processes and communicate findings to leadership to ensure competitiveness in the market • Manage relationships with vendors, internal stakeholders, and I/S to ensure alignment on digital priorities, DX-driven communication strategies, and the successful execution of projects

• Responsible for responding to customer inquiries • Performs research as needed to resolve inquiries • Reviews and adjudicates claims and/or non-medical appeals • Determines whether to return, deny or pay claims following organizational policies and procedures • Ensure effective customer relations by responding accurately, timely, and courteously to inquiries • Handles situations which may require adaptation of response or extensive research • Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines • Ensure claims are processing according to established quality and production standards • Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines

Role Description Rates and designs benefits for largest and most complex groups. Serves as primary contact to stop loss vendors. Qualifications - Required Education: Bachelor's Degree or 4 years job related work experience or Associate's and 2 years job related work experience - Required Work Experience: 5 Years underwriting experience - Required Skills and Abilities: - Excellent organizational, customer service, oral and written communication skills - Excellent mathematical, analytical and critical thinking skills - Good judgment - Ability to handle confidential or sensitive information with discretion - Proficient spelling, punctuation, and grammar - Extensive knowledge of underwriting and risk principles and their application - Required Software and Other Tools: Microsoft Office Requirements - Preferred Education: Bachelor's degree in Accounting, Finance, Business or Healthcare Administration, Statistics, Mathematics, or related field - Preferred Work Experience: 7 Years underwriting experience - Preferred Skills and Abilities: Insurance course work in FLMI, HIAA, or BCA - Preferred Software and Other Tools: Knowledge of database software and computer systems support; Prior Ugan experience 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

• Develops and executes marketing plans for new sales and/or retention of existing accounts within assigned territory • Prepares and presents proposals and communications to groups, agents, and/or individuals • Develops and maintains professional relationships with groups, agents, and/or individuals • Assesses agency, agent, group, and/or individual sales opportunities and works with groups, agent, and/or individuals to resolve problem issues • Conducts on-going market research and provides key information that may lead to sales • Prepares and submits required marketing reports to management detailing how best to position company products • Maintains product/industry knowledge and marketing skills by attending trading seminars, continuing education classes, conferences, etc.

• 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 inner workings 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.

Role Description Performs quality control audits to evaluate accuracy and effectiveness of departmental operations functions including, but not limited to, claims, membership, customer service/call center, workflow, processing support systems, procedures, documentation, etc. Identifies problems, analyzes cause and effect, and makes recommendations for improvements. This role is remote full time M-F 8am-5pm. This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. 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 Will Do: - Conducts focused quality audits across various operations functions to ensure quality standards, procedures, and methodologies are being followed. - Documents findings of analysis and prepares recommendations for implementation of new systems, procedures, or organizational changes to reduce errors. - Identifies areas of weakness and communicates recommendations on changes and improvements to training materials. - Provides feedback to management on errors detected, ensures errors are resolved, and provides long-range solutions to causes. - Develops and implements a quality control and improvement program based on targets identified through the quality reviews. - Monitors and evaluates the implementation of corrective action plans. - Compiles data, provides feedback, and generates reports for operations and/or training areas on quality performance. - Trains new employees and remains current with all guideline changes, work instructions, etc. - Writes or assists in writing desk procedures and training materials for departments. - Provides assistance with special projects such as testing for new business implementation or system changes, reviewing change requests, interpreting department workload, statistical reports, assisting co-workers, etc. Qualifications - High School Diploma OR equivalent. - 1 year of related claims processing, customer service, auditing, training, analysis or operations experience. - 2 years of experience performing quality audits. - Strong analytical, presentation, customer service, persuasion, and organization skills. - Strong business math proficiency. - Able to document problems and assist in their resolution. - Able to document processes and identify areas for improvement. - Strong written and verbal communication skills. Requirements - Microsoft Office proficiency. 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.

• 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 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

• Manages day-to-day operations of credentialing area to include delegated credentialing activities. • Develops/implements credentialing policies/procedures/evaluation tools. • Evaluates/monitors/ensures compliance with National Committee of Quality Assurance (NCQA) and other regulatory standards/external review bodies. • Conducts on-site audits and inspections of delegated entities/provider files. • Communicates with/responds to internal and external representatives regarding data, delegation agreements, facility credentialing, and sanction issues. • Works with other departments to address/resolve credentialing issues. • Promotes efficiency through planning, problem solving, and application of industry standards. • Maintains accurate/current/efficient databases. • Coordinates/manages all activities and follows-up for credentialing committee. • Presents physicians/practitioners/providers with quality issues to committee for review. • Selects/trains/develops/guides staff and ensures excellent customer service is given to employees/customers/management, etc. • Monitors department performance and productivity. • Performs quality control functions for work performed. • Makes recommendations on process improvements and identifies training needs for staff.

Role Description Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Qualifications - Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling. - 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, 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. Requirements - 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 LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist 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.