Jobs at BlueCross BlueShield of South Carolina

Lead and grow reinsurance and provider excess-loss business by building broker and health-plan relationships, overseeing underwriting and sales, setting metrics and financial goals, ensuring compliance, developing marketing strategies, managing budgets, and maintaining high broker/agent satisfaction and product competitiveness.

Responsible for accurate and timely processing of claims, coordinating with internal departments, and verifying coding of procedures and diagnoses.

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

Perform focused quality control audits across claims, membership, customer service, workflow, and processing systems. Document findings, recommend improvements, develop and monitor corrective actions, produce quality reports, train staff, and assist with special projects and procedure/training material writing.

Lead design and approval of cross-platform technical solutions, create design artifacts, run design sessions, coordinate with architects and teams, ensure solutions meet business requirements, mentor staff, and maintain architectural and project standards.

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

The Appeals Specialist processes non-medical reviews and redetermination letters, ensuring accuracy and timeliness, prepares reports, and handles documentation for inquiries.

Perform quality control audits across claims, membership, call center, and operations functions; document findings; recommend improvements; develop and monitor corrective action plans; train staff; write procedures and training materials; compile reports and support special projects and system changes.

Assist in executing financial, compliance, and operational audits, evaluate internal controls, and prepare reports on audit results. Conduct special audits and support other auditors to enhance efficiency.

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

Maintain, install, test, and debug mainframe systems software (operating systems, databases, networked systems). Provide disaster recovery support, participate in audits, cross-train for on-call rotation, and mentor junior staff. Work under minimal supervision.

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.

Process and key member enrollment transactions including new enrollments, terminations, changes, and renewals. Maintain and update electronic enrollment files, resolve customer and administrator inquiries, work edit/error reports, coordinate with operational areas, prepare materials (contracts, ID cards), and participate in enrollment, billing, and reconciliation projects.

Process and research health insurance claims accurately and timely. Verify procedure and diagnosis codes, resolve system edits and errors, coordinate with internal departments to update patient, insurance, and provider records per guidelines.

Support and maintain the enterprise CICS/mainframe transaction-processing environment. Diagnose and debug system software, design and coordinate system builds and changes, schedule downtime, review security patches and audit requirements, provide technical guidance to projects, evaluate vendor software, and support disaster recovery and data center operations to ensure high availability and performance.

As a Case Management Coordinator, you will focus on care coordination, assessment, planning, and implementation of care plans while collaborating with clients and health professionals.

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.

Provide telephonic case management for members (especially NICU/maternity), assess needs, develop and coordinate care plans, ensure documentation for medical necessity and benefits, perform utilization review/authorization, communicate with providers/members, and refer to internal resources while complying with regulatory standards.

Under general supervision, interprets and analyzes benefit plan designs, creates specifications for programming, programs/audits benefit data and RULEs, coordinates testing with IT and business lines, and develops process solutions to ensure accurate claims adjudication and eligibility.

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.