Jobs at BlueCross BlueShield of South Carolina

Oversee and implement a comprehensive contract compliance program for commercial and government products. Manage regulatory filings and approvals, review and draft contracts and related documents, negotiate with regulators, monitor regulatory changes, respond to regulatory complaints, troubleshoot policy/certificate issuance systems, and supervise compliance staff including licensing and training. Ensure HIPAA, OFAC, Patriot Act and other federal/state regulatory compliance.

Maintain and update provider files in PIMS/AMMS, run and analyze provider reports, resolve provider issues related to eligibility and billing, support system testing and special projects, and ensure data accuracy and confidentiality.

Prepare and analyze complex accounting transactions, journal entries, and reconciliations; develop rates and proposal cost documentation; produce financial reports, budgets, and forecasts; lead special projects and audits; review and improve policies and mentor junior staff.

Perform prior authorization utilization management reviews, evaluate medication safety and cost-effectiveness, communicate recommendations to prescribers and members, coordinate with care/disease management teams, and contribute to clinical rule and decision-tree development to optimize medication outcomes.

Designs and executes complex database programs and sampling for standard and ad-hoc reporting. Performs advanced statistical analyses, data extraction, validation, and visualization. Prepares narrative reports, supports project lifecycle tasks, and collaborates cross-functionally to ensure regulatory compliance and reporting quality.

Manage daily operations of claims/documents processing and customer service teams, ensuring productivity, quality, contract compliance, training, reporting, and leading process improvement and policy change initiatives. Support budgeting and oversee staff performance and quality control.

Create and maintain healthcare provider files in PIMS/AMMS to support provider directories, claims adjudication, and billing. Verify provider information, assign networks, run maintenance/error reports, and participate in projects like audits and mass updates.

Establishes and maintains healthcare provider certification and files to support provider directories, claims adjudication, and billing. Updates provider data in PIMS/AMMS, assigns providers to networks, runs maintenance/error reports, and supports special projects like audits and mass updates.

The Accountant III-CDS reconciles general ledger accounts, processes complex transactions, ensures compliance with regulations, and trains junior accountants at BlueCross BlueShield of South Carolina.

Process and research insurance claims accurately and timely, verify procedure and diagnosis coding, resolve system edits and errors, coordinate with internal departments to update patient, provider and other insurance records.

Audit and authorize medical stop loss claims, ensuring proper reimbursement and effective claims mitigation while providing customer service.

Provide reinsurance support for new and renewal business including underwriting, claims audit/record keeping, billing/payment calculations, policy changes, and customer service. Coordinate communications with reinsurers and internal teams, run and maintain reports and logs, process endorsements and refunds, and ensure documentation accuracy and timely responses.

Make inbound and outbound calls to sell insurance products, follow up on leads, process applications, prepare marketing packets, and maintain records. Obtain required state insurance license within 60 days and Medicare certification within 90 days.

Performs non-medical appeals reviews and processes redetermination letters. Prepares unit reports, analyzes workload, updates departmental documents, and may gather documentation for legal or administrative inquiries. Ensures timeliness, accuracy, and proper use of software tools in a typical office environment.

Lead regional sales, renewals, and service operations; recruit, train, and manage sales teams; develop regional marketing and budgets; coordinate account implementation, renewals, and issue resolution; build relationships with clients, brokers, and partners to drive growth and retention.

Designs and delivers instructor-led and virtual training programs, conducts training needs assessments, develops assessments and materials, coaches trainees and training specialists, tracks performance, and coordinates with management to meet project deliverables.

Perform full lifecycle systems analysis and software development: design, code, test, debug, document, and maintain systems. Lead legacy data migration, integration, and testing efforts; prepare specifications and research scope to develop and improve complex systems.

Design, code, maintain, and run programs to extract, analyze, verify, and present data for standard and ad hoc reporting. Support development of statistical analyses and models, assist with project plans, system life cycle tasks, change requests, test plans, and database management.

Sell, renew, and service individual and group accounts within an assigned territory through outside sales. Develop and execute marketing plans, present proposals, perform market research, build agent and client relationships, maintain product knowledge, and submit marketing reports to management.

Lead solutions management across clinical, pharmacy, wellness, and ancillary offerings; manage Wellbeing Consultants; drive sales enablement, retention, partner plan relationships, performance reporting, and service delivery to meet growth and client retention goals.