Jobs at BlueCross BlueShield of South Carolina

Supervises case management, utilization review, medical review, health management, quality management, and appeals functions. Leads staff, oversees specialty program implementation, maintains procedures and audit standards, conducts quality control, analyzes program data, prepares reports, and ensures URAC/NCQA compliance. Coordinates across departments and supports effective healthcare service delivery.

Administer, maintain, troubleshoot, and optimize IBM z/OS mainframe systems software. Install patches and upgrades, analyze complex issues, support audits, execute disaster recovery procedures, and participate in 24x7 on-call operations. The role also provides technical leadership, coaching, and mentoring while supporting high-availability, mission-critical enterprise systems.

Responsible for identifying training needs, developing materials, and facilitating training. Provides guidance and leadership for new specialists and evaluates training effectiveness.

Coordinate and conduct internal ISO 9001:2015 audits, track and report corrective/preventive actions, maintain document control, support external audits, provide training, and analyze quality data to drive process improvements.

Develop and deliver provider education and training materials (workshops, teleconferences, web content). Support provider relationships, respond to educational needs, perform administrative tasks and reporting, and contribute to special projects.

Provide first-level telephone and written support for EDI products and services, manage customer service logs, track requests in a relational database, assist with electronic transaction setup and submitter testing, and support monthly audits and interdepartmental request processing.

Processes non-medical appeals and redetermination letters with accuracy and timeliness. Prepares reports, analyzes workload, resolves issues using software tools, updates departmental letters and documents, and gathers documentation for legal or administrative requests. The role requires strong communication, organization, judgment, proofreading, Microsoft Office proficiency, and experience working across multiple systems. Medical claims, appeals, coding, Medicare Part B, and intermediate Excel experience are preferred.

Processes claims accurately and promptly by researching claim information, verifying procedure and diagnosis coding, resolving system edits and errors, and coordinating updates across internal departments. The role requires reviewing patient, provider, and insurance records, applying business regulations and processing guidelines, and maintaining accurate claim files in an on-site office environment.

Develop, modify, test, and document application software across the SDLC. Collaborate with analysts and team members to translate business requirements into technical solutions, implement and debug code, create test files/data, and ensure timely delivery and quality of applications supporting internal users and external Medicare customers.

Perform general ledger reconciliations, prepare and post journal entries, produce financial reports and spreadsheets, analyze variances, maintain work papers, assist internal/external audits, key invoices into A/P, and support special projects and supervisory reviews. Requires use of Microsoft Office and data retrieval tools.

Review and adjudicate complex or specialty insurance claims to determine return, denial, or payment per policy. Verify coding, enter claims, correct processing errors, research edits/deferrals, coordinate with internal teams, respond to correspondence, and mentor new staff.

Maintain and advise on mainframe storage technologies, infrastructure products, and operational processes. Develop technology roadmaps, lifecycle plans, standards, policies, best practices, and procedures. Collaborate with vendors, operations, architecture, and management teams; research technology developments and evaluate integrations. Preferred expertise includes IBM z/OS storage administration, HSM, DASD, DFSMS, SMS constructs, Luminex virtual tape, IBM TDMF, Dell EMC PowerMax, SRDF replication, and zEDC.

Extract and report enrollment and financial data to develop competitive rates and meet profitability goals. Build actuarial models and reporting for new products, maintain rating system tables and documentation, produce monthly and ad hoc reports, support underwriting and actuarial staff, document regulatory submissions, and perform profitability analysis across lines of business.

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.

Manage daily operations of multi-functional claims and customer service teams, monitor productivity, quality, and attendance, oversee compliance and quality control, lead process improvement and system change projects, and assist with budget preparation and expense monitoring.

Manage day-to-day underwriting operations, supervise staff, enforce underwriting policies, analyze risk and profitability, oversee servicing carrier operations, maintain agent and reinsurer relationships, ensure compliance, produce reporting, and support director on special projects.

Extract, manipulate, and analyze data from multiple systems to produce regular and ad hoc reports. Build statistical models, summarize findings for management, identify process improvements, and support operational reporting and communication across departments.

The candidate will perform application analysis, design solutions, maintain programs, and analyze existing systems for enhancements, ensuring timely delivery of software.

Lead actuarial initiatives for the pharmacy line of business, ensuring compliance, developing pricing strategies, and managing staff and projects.