BlueCross BlueShield of South Carolina

This role serves as a team lead, coordinating area processes such as work distribution, database logging, processing group changes, and responding to inquiries. Key duties include training new employees, monitoring workloads, preparing reports, issuing contracts, and ensuring accurate processing of enrollment, renewals, and billing for assigned groups.

This role is responsible for supervising the receipt, review, and settlement of the Medicare cost report, ensuring strict adherence to all Centers for Medicare and Medicaid Services (CMS) requirements. Key duties include performing supervisory review of all team audit work papers and settlement packages, planning and budgeting team work, and assisting in staff development through training.

The analyst will review, extract, and analyze data to formulate procedures and processes, providing reports to identify problematic areas for modification or elimination. They will also design, code, and maintain complex database programs for data extraction and analysis to support financial and operational decisions.

The role involves providing support to members for disease prevention and health promotion by empowering them to achieve optimal health through personalized guidance and education. This includes assessing chronic condition needs, coordinating action plans, and utilizing coaching techniques to elicit behavior change and increase program engagement.

Medical Director overseeing administrative functions and medical policies

We are currently hiring for a Stop Loss Registered Nurse to join BlueCross BlueShield of South Carolina. In this role as a Stop Loss Registered Nurse, you will evaluate and manage catastrophic episodes of illness for underwriting and claims. Ensures that the insured is receiving ...

This role involves coordinating and performing testing for major system enhancements, including reviewing documents for testing, creating test matrices, and executing test cases. Functions as a liaison between the operations areas and Information systems by researching technical ...

Medical Informatics Administrator integrating clinical data at BlueCross BlueShield of South Carolina

Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote. Our ideal candidate must reside in South Carolina and may be required to conduct occasional member-facing patient visits within SC. What You’ll Do: Functions as team le...

Performs medical and pharmacy utilization reviews using established guidelines; determines eligibility and medical necessity, documents decisions, supports discharge planning, educates members/providers, reviews claims, and refers complex cases to clinical staff.