BlueCross BlueShield of South Carolina

• Provide prompt, accurate, thorough and courteous responses to customer inquiries • Perform research as needed to resolve inquiries • Ensure effective customer relations by responding accurately, timely and courteously to inquiries • Accurately document inquiries • Initiate or process adjustments or perform other research as needed to resolve inquiries • Coordinate with other departments to resolve problems • Provide feedback to management regarding customer problems, questions and needs • Maintain accurate records on complaints and/or other customer comments • Make recommendations for changes to management • Follow through on complaints until resolved or report to management as needed • Assist with process improvements • Identify and promptly report suspected fraudulent activities and system errors

• The Automation Specialist is responsible for identifying, developing, and implementing process improvements and automation solutions that enhance operational efficiency within the Audit Reimbursement Department. • Evaluates existing policies, procedures, and workflows to recommend improvements ranging from process optimization to complete procedural redesigns when necessary. • Collaborates with department stakeholders to streamline operations, reduce manual effort, improve accuracy, and support continuous improvement initiatives. • 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. • 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.

• Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy. • Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools. • Updates letter's and documents within the department when necessary. • May gather and prepare documentation for legal inquiries and administrative requests.

• 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, and 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 • 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

Role Description Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Logistics: - Companion Life | Insurance Company | Based in Columbia, SC – one of BlueCross BlueShield's South Carolina subsidiary companies. - This position is full-time (40-hours/week) Monday-Friday. You will work an 8-hour shift scheduled during our normal business hours. - This role is remote. What You’ll Do: - Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier. - Recognize cost mitigation opportunities. - Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits. - Initiate claims investigations and vendor referrals. - Interpret plan language, and identify experimental services and subrogation opportunities. - Identify need for follow-up on pended claims and resolution. - Communicate effectively with carriers, vendors, and management. - Provide full claims service to both phone and written inquiries. - Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history. - Develop new and review old stop loss claim forms. - Assist with internal auditing of claims auditors, and training of claims auditors. Qualifications - Associate's degree - 6 years of managed care or reinsurance claims experience. Requirements - Analyzes laws, regulations and contract language. - Evaluates issues and develops recommendations. - Handles confidential and sensitive information. - Investigates assigned claims. - Proposes claims adjustments and refunds. - Works claims caseloads. Benefits - 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. Pay Transparency Statement - Range Minimum: $51,107.00 - Range Midpoint: $74,418.00 - Range Maximum: $97,729.00 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. 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.

• Perform medical claim reviews for claims requiring preauthorization or appeals • Determine medical necessity and appropriateness for coverage and reimbursement • Document medical rationale for payment or denial of services • Educate staff on medical reviews, coverage determinations, and coding procedures • Participate in quality control activities

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation • Identifies, documents, and evaluates business risks • Documents issues, the causes of those issues, and their effects on the process/function and the corporation • 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 • Reviews findings and identifies recommendations to correct deficiencies and methods for process improvements • Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity • Conducts special audit studies for management to discover controls for fraud prevention • Prepares reports of findings and recommendations for management

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits • Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement • Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans • May identify, initiate, and participate in on-site reviews • Serves as member advocate through continued communication and education • Promotes enrollment in care management programs and/or health and disease management programs • Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members • Performs medical or behavioral review/authorization process • Ensures coverage for appropriate services within benefit and medical necessity guidelines • Utilizes allocated resources to back up review determinations • Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.) • Participates in data collection/input into system for clinical information flow and proper claims adjudication • Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal) • Maintains current knowledge of contracts and network status of all service providers and applies appropriately • Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services

• Conducts internal and/or external timely operational, financial, and/or compliance audits • Identifies, documents, and evaluates business risks • Develops written audit programs • Conducts testing and analysis of existing controls • Prepares written work papers to document testing results • Documents issues, causes of those issues, and their effects • Serves as Lead Auditor on complex audit assignments • Drafts recommendations to limit risks and improve processes • Writes audit reports for corporate executive management • Collects and analyzes data to detect deficient controls • Conducts testing of corrective actions • Develops detailed reports on each audit conducted • Examine and evaluate financial and information systems • Conducts special audit studies for management • Provides training to other auditors

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members • Monitors services and implements plans, to include member goals • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits • Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions • Participates in direct intervention/patient education with members and providers regarding health care delivery system • May identify, initiate, and participate in on-site reviews • Serves as member advocate through continued communication and education • Promotes enrollment in care management programs and/or health and disease management programs • Provides appropriate communications (written, telephone) regarding requested services to health care providers and members • Performs medical or behavioral review/authorization process • Ensures coverage for appropriate services within benefit and medical necessity guidelines • Identifies and makes referrals to appropriate staff