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
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
Nashville, Tennessee, United States · Hybrid
Summary Provides all redetermination case file information within the specified time requirement while maintaining accuracy and departmental standards. Suspends claims in applicable claim system and tracks all data. Desc…
Skills: Administrative support, Clerical, Claims processing, Organizational skills, Decision making
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: Training needs assessment, Instructional design, Classroom facilitation, Project management, Performance assessment
Columbia, South Carolina, United States · Hybrid
$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: Clinical leadership, Utilization review, Medical policy development, Case management, Quality assurance
Nashville, Tennessee, United States · On-site
Summary CGS Administrators, LLC (CGS) is part of BCBSSC™'s Celerian Group of companies and provides a variety of services for Medicare beneficiaries, healthcare providers, and medical equipment suppliers in 38 states, su…
Skills: C#, MS SQL, OnBase, System development lifecycle, Systems analysis
Columbia, South Carolina, United States · Hybrid
Summary Responsible for performing comprehensive medication reviews and outreach to inform and educate patients and their providers about opportunities to optimize medication related outcomes, ensure patient safety, and …
Skills: Utilization management, Prior authorization, Clinical pharmacy, Medication therapy management, Evidence based medicine
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, Financial reconciliation, Excel, General ledger, Financial reporting
Jacksonville, Florida, United States · Remote Solely
$51k–$98k/yr
Summary Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Why should you join the BlueCross BlueShield of…
Skills: Claims auditing, Medical stop loss, Cost mitigation, Claims investigation, Reimbursement authorization
Columbia, South Carolina, United States · Remote OK
Summary Provides care management services to more than 2 million members in South Carolina and nationally. Administers complex, high-touch concierge case management for members identified into specialized programs such a…
Skills: Case Management, Care Coordination, Clinical Services Coordination, Risk Identification, Care Planning
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: Managed Care Contract Negotiations, Hospital Reimbursement Methodologies, Financial Planning, Budget Control, Executive Presentation Skills
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 Location: This position is full-time (40-hours/week) Monday-Fr…
Skills: Bilingual Spanish and English, Customer Service, Claims Processing, Verbal Communication, Written Communication
Columbia, South Carolina, United States · On-site
Summary Provides direction and guidance to appeals, customer service, and claims processing staff for multiple operational areas. We strongly prefer experience in FISS, MAS, PECOS, and HIGLAS and management in a Medicare…
Skills: Budget Management, Staff Supervision, Claims Processing, Appeals Management, Customer Service
Columbia, South Carolina, United States · Hybrid
Summary Empowers sales team to operate at maximum efficiency and effectiveness by streamlining processes, managing key documentation, and providing essential support during critical sales cycles. Acts as the primary liai…
Skills: RFP Process Management, Sales Enablement, Project Management, Microsoft Office Suite, CRM Systems
Columbia, South Carolina, United States · Hybrid
Summary This high-level proposal resource will participate in winning and retaining large clients, primarily designated to strategic RFPs and RFIs with a focus on strategy, storytelling, and high-quality responses. This …
Skills: Proposal Development, RFP Analysis, Storytelling, SWOT Analysis, Stakeholder Coordination
Columbia, South Carolina, United States · Hybrid
Summary Cultivates relationships with key partners, stakeholders, and influencers in the community. Delivers presentations, attends community events/meetings, and distributes materials. Works with corporate communication…
Skills: Public Speaking, Presentation Skills, Community Outreach, Relationship Management, Bilingual English and Spanish
Nashville, Tennessee, United States · On-site
Summary Working at CGS Administrators CGS Administrators, LLC (CGS) is part of BCBSSC™'s Celerian Group of companies and provides a variety of services for Medicare beneficiaries, healthcare providers, and medical equipm…
Skills: IT Business Analysis, Requirements Elicitation, Healthcare Domain Knowledge, Medicare/Medicaid Systems, Agile Methodology
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, Financial Analysis, Account Reconciliation, General Ledger Management, Microsoft Excel
South Carolina, United States · Remote OK
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: Business Systems Analysis, VBA Scripting, Excel Macro Development, User Acceptance Testing, Process Optimization
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: Inventory Balancing, Reconciliations, Journal Entries, Accounts Payable, Accounts Receivable
Columbia, South Carolina, United States • On-site
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The officer will lead strategic initiatives to improve Medicare Advantage Star ratings and optimize risk adjustment performance. They are responsible for managing cross-functional teams, communicating performance metrics to senior leadership, and fostering relationships with providers and vendors.
Candidates must have at least 10 years of experience in the healthcare or insurance industry, including 3 years of Medicare Advantage Stars Rating experience. A bachelor's degree is required, along with advanced proficiency in Microsoft Office tools like Excel and PowerPoint.
Location: This position is full-time (40-hours/week) Monday-Friday working ONSITE at our Government Programs Complex at 17 Technology Circle, Columbia, SC location.
Develop and implement strategic plans to improve the Stars ratings for Medicare Advantage programs.
Ensure that plans are continuously evaluated and any modifications are implemented in a timely manner.
Build relationships with, and lead, cross-functional teams to drive Stars rating initiatives and best practices by promoting innovation, strategy development, and implementation excellence.
Effectively communicate performance progress, new initiatives needed for higher performance, organizational barriers, and expectations of results to senior leadership.
Develop reports for senior leaders and internal stakeholders. Present findings of improvement efforts, ongoing performance measures, and recommended actions plans.
Build and maintain effective relationships with providers and vendors.
Develop and implement strategies to engage, education, and motivate providers. Effectively manage vendors and hold them accountable for high performance.
Drive positive culture transformation and corporate-wide awareness of Stars through education, communication, and employee engagement.
Develop and refine internal education. Stay abreast of, and keep the organization apprised of, existing and new legislation impacting Stars ratings.
Provide oversight to Stars team.
To Qualify for This Position, You'll Need the Following:
Required Education: Bachelor's degree.
10 years of experience in insurance, healthcare, or similarly complex industry;
Concurrent experience includes: 5 years of health plan experience;
3 years of management experience OR 3 years of equivalent military experience in grade E4 or above;
3 years of Medicare Advantage Stars Rating program experience.
Required Software and tools: Microsoft Office suite, including advanced PowerPoint and Excel skills
Required Skills and Abilities:
Ability to effectively lead organization wide initiatives.
Ability to develop and lead high performing team.
Excellent communication and interpersonal skills.
Ability to set priorities, meet objectives for complex projects involving multiple stakeholders, and execute according to plan.
Ability to build effective relationships with cross-functional teams and external stakeholders.
Ability to work across all levels of the organization, including work with individual contributors, executive and management audiences, physicians and vendors.
Stars leadership position in a high performing (4+ Stars) Medicare Advantage health plan. Hands-on Risk Adjustment and value-based program experience.
Master's degree or RN.
HEDIS 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
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.
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.
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.
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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
