Winnipeg, Manitoba, Canada · Remote OK
$206k–$414k/yr
Summary 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 em…
Skills: Medical policy development, Utilization review, Case review, Claim adjudication, Regulatory compliance
Florence, South Carolina, United States · On-site
Summary We are currently hiring for a Claims Processor I to join BlueCross BlueShield of South Carolina. You will be responsible for the accurate and timely processing of claims. Why should you join the BlueCross BlueShi…
Skills: Analytical skills, Organizational skills, Customer service, Oral communication, Written communication
Columbia, South Carolina, United States · On-site
Summary Description 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 roo…
Skills: Cost accounting, Excel, Financial reconciliation, General ledger, Budgeting
Columbia, South Carolina, United States · Hybrid
Summary Leads solutions management across the healthcare continuum, including clinical, pharmacy, wellness, and ancillary offerings. Oversees a team of Wellbeing Consultants and ensures effective sales enablement, retent…
Skills: Solutions Management, Sales Enablement, Client Retention, Healthcare Continuum, Resource Planning
Columbia, South Carolina, United States · Remote OK
Summary Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events (serious, preventable medical errors) for all lines of business. Coordinates rate adjustments with…
Skills: Medical record management, Coding, Validation review, DRG, APC
South Carolina, United States · Remote OK
Summary We are currently hiring for an Intensive Care Management Coordinator to join BlueCross BlueShield of South Carolina. In this role as an Intensive Care Management Coordinator, you will serve as an Intensive Case M…
Skills: Case management, Behavioral health, Care coordination, Clinical assessment, Patient advocacy
Winnipeg, Manitoba, Canada · Remote OK
$206k–$414k/yr
Summary 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 em…
Skills: Medical policy development, Utilization review, Case review, Claim adjudication, Regulatory compliance
Columbia, South Carolina, United States · On-site
Summary Under general supervision, responsible for interpreting, reviewing, and analyzing benefit plan designs. Responsible for creating scope, design and specification documents for programming of benefits from benefit …
Skills: Systems analysis, Statistical analysis, Claims processing, Computer programming, Analytical skills
Nashville, Tennessee, United States · Hybrid
Summary We are currently hiring for a Claims Customer Service Advocate II to join CGS/BlueCross BlueShield of South Carolina. You will be responsible for responding to customer inquiries. Inquiries may be non-routine and…
Skills: Customer service, Claims processing, Appeals processing, Verbal communication, Written communication
Florence, South Carolina, United States · On-site
Summary Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions. De…
Skills: Customer Service, Claims Processing, Appeals Processing, Verbal Communication, Written Communication
Columbia, South Carolina, United States · On-site
Summary Coordinates market conduct and regulatory reporting activities. Researches and interprets state and federal insurance laws and regulations pertaining to marketplace activity, including privacy and security measur…
Skills: Regulatory compliance, Contract analysis, Auditing, Legal research, Data analysis
Kansas, Illinois, United States · Hybrid
Summary Leads corporate distribution systems, general agents, brokers, and other market support personnel. Responsible for planning, product development, marketing services, production and profitability for as few as two…
Skills: Insurance sales, Insurance marketing, Sales negotiation, Product development, Relationship management
Florence, South Carolina, United States · On-site
Summary Provides prompt, accurate, thorough and courteous responses to all telephone inquiries. Performs research as needed to resolve inquiries. Description Logistics: This position is a full-time Mon- Friday 8:00am to …
Skills: Verbal communication, Human relations, Organizational skills, Stress management, Judgment
Columbia, South Carolina, United States · Hybrid
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 em…
Skills: AI security, Security architecture, Risk management, Data governance, Privacy compliance
Columbia, South Carolina, United States · On-site
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 roo…
Skills: Accounting, Reconciliations, Inventory balancing, Data entry, Financial reporting
Nashville, Tennessee, United States · On-site
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 em…
Skills: Accounting, Financial reporting, Data entry, Reconciliation, Inventory balancing
Columbia, South Carolina, United States · Hybrid
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 em…
Skills: Cobol, Mainframe, Systems analysis, Programming, Debugging
Columbia, South Carolina, United States · On-site
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 roo…
Skills: Accounting, Reconciliations, Inventory balancing, Data entry, Financial reporting
Nashville, Tennessee, United States · Hybrid
Summary Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identi…
Skills: Medical review, Utilization review, Medicare regulations, Team leadership, Process improvement
Columbia, South Carolina, United States · On-site
Summary 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 em…
Skills: Medicare Advantage, Stars rating improvement, Risk adjustment, HCC coding, RAF score optimization
Winnipeg, Manitoba, Canada • Remote OK
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The Medical Director provides administrative oversight to medical staff, analyzes utilization data, and develops claim adjudication criteria. They also act as a liaison between the company and the medical community while researching new medical procedures and technologies.
Candidates must hold a doctorate in a job-related field and possess at least 5 years of post-graduate experience in direct patient care. An active state medical license and current board certification in a recognized specialty are required.
Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This position is full-time (40-hours/week) Monday-Friday working REMOTE in the United States or ONSITE at our GPC location at 17 Technology Circle, Columbia, SC. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM.
Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You’ll Do:
Supports operations in the form of case review on both medical and regulatory matters.
Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.
Educates staff and medical community on various aspects of medical policy and program administration.
May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
Conducts research into new or controversial medical procedures and technology.
To Qualify for This Position, You'll Need the Following:
Required Education: Doctorate in a job related field.
Required Experience:
5 years post graduate experience in direct patient care.
Required Software and tools: Microsoft Office
Required Skills and Abilities:
Excellent verbal and written communication skills.
Excellent customer service, organizational, and presentation skills.
Good judgment skills. Proficiency in spelling, punctuation, and grammar.
Ability to persuade, negotiate, or influence others.
Ability to work as a team member as well as a leader.
Knowledge of medical and utilization review techniques.
Required Licenses and Certifications: Active state medical license and current board certification in a recognized specialty.
We Prefer That You Have the Following:
Health insurance industry experience
Experience in INPATIENT Rehabilitation
Medicare policy knowledge and experience
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.
Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.
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.
Pay Range Min:
$206,011.00
Pay Range Mid:
$309,767.00
Pay Range Max:
$413,523.00
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.
South Carolina’s largest and oldest health insurance company
For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state. We are the largest insurance company in South Carolina. We are also the only one that has an A+ Superior A.M. Best rating. We are one of the nation's leading government contract administrators. We operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies. Our full-time employees enjoy benefits like a 401(k) retirement savings plan with company match, subsidized health plans, free vision coverage, life insurance, paid annual leave and holidays, wellness programs and education assistance. If you are a full-time employee in the National Guard or reserves, we will cover the difference in your pay if you are called to active duty. BlueCross has a dedicated corporate culture of community support. Our employees are some of the most giving in the country. They support dozens of nonprofit organizations every year. If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now! BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. We are an Equal Opportunity Employer. We will consider all qualified applicants for employment 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.
Offices: I-20 E at Alpine Road, Columbia, South Carolina 29219, US
South Carolina’s largest and oldest health insurance company
For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state. We are the largest insurance company in South Carolina. We are also the only one that has an A+ Superior A.M. Best rating. We are one of the nation's leading government contract administrators. We operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies. Our full-time employees enjoy benefits like a 401(k) retirement savings plan with company match, subsidized health plans, free vision coverage, life insurance, paid annual leave and holidays, wellness programs and education assistance. If you are a full-time employee in the National Guard or reserves, we will cover the difference in your pay if you are called to active duty. BlueCross has a dedicated corporate culture of community support. Our employees are some of the most giving in the country. They support dozens of nonprofit organizations every year. If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now! BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. We are an Equal Opportunity Employer. We will consider all qualified applicants for employment 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.
Offices: I-20 E at Alpine Road, Columbia, South Carolina 29219, US
