Jobs at BlueCross BlueShield of South Carolina

Processes and adjusts pre-pay and post-pay medical claims, investigates denials and claim histories, prescreens records for nursing review, maintains accurate records, monitors processing timeliness, performs quality control, communicates with providers, and supports special projects.

Processes healthcare claims accurately and promptly by researching claims, verifying procedure and diagnosis codes, resolving system edits and errors, and coordinating updates to patient, insurance, and provider records. The role requires strong analytical, organizational, communication, grammar, judgment, and business math skills. It is a full-time, on-site position supporting government contract operations.

Manages contract administration staff and oversees compliance, performance, reporting, documentation, and financial management for government contracts. Leads proposal preparation, FAR and Cost Accounting Standards compliance, contract and subcontract negotiations, legal document approvals, departmental process development, ISO documentation, staff training, and business planning. Maintains relationships with customer contracting officers and advises management on contractual risks, policies, and process improvements.

Reviews, researches, verifies, and processes provider enrollment applications and maintains provider file integrity. Enters and updates provider data, validates information through databases and external agencies, resolves discrepancies, supports EFT setup, responds to inquiries, and assists with system testing, process improvements, provider education, and training. The role also ensures compliance with enrollment standards, Medicare requirements, and applicable guidelines.

Processes healthcare claims accurately and on time by researching claims, verifying procedure and diagnosis coding, resolving system edits and errors, and coordinating with internal departments to update patient, insurance, provider, and related records. The role requires a high school diploma, analytical and communication skills, business math knowledge, and basic office software proficiency. Healthcare or insurance experience and advanced software and mathematical skills are preferred.

Perform detailed research on claims to prevent aging and erroneous disbursements, validate and escalate questionable claims, monitor inventory reports, provide documentation for audits, and support billing/crediting adjustments and fraud investigations.

Provides clerical and administrative support for a medical review team by processing claim denials and adjustments, investigating claim histories, prescreening records, maintaining accurate documentation, monitoring timeliness, and performing quality control. Communicates with providers regarding denials and supports special projects. The position is full-time and onsite, with minimal phone contact.

Coordinates care management for members with chronic conditions, high-risk pregnancies, and other complex needs. Assesses service requirements, develops action plans, monitors outcomes, supports medical necessity reviews, educates members and providers, coordinates referrals, advocates for members, and ensures compliance with benefit, contract, and regulatory requirements.

Processes healthcare claims accurately and promptly by researching claims, verifying procedure and diagnosis coding, resolving system edits and errors, and updating patient, provider, and insurance records. The role follows business regulations, internal standards, and processing guidelines while coordinating with internal departments. It is a full-time, on-site position requiring a high school diploma, strong analytical and communication skills, basic business math, and the ability to obtain a security clearance.

Reviews and adjudicates complex or specialty insurance claims, determining whether to return, deny, or pay them according to policies and regulations. Processes claims using coding and diagnosis verification, researches edits and deferrals, corrects errors through adjustments or recoupments, and maintains quality and production standards. The role also responds to correspondence, completes spreadsheets, and assists with training or mentoring 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.

Provides blended learning solutions by facilitating technical and non-technical training, assessing learner needs, designing instructional materials, evaluating course effectiveness, and maintaining training systems. Partners with subject matter experts and business teams to address performance gaps, support training plans, and manage administrative training functions. Delivers orientation, job-specific, company-specific, and e-learning programs for new and existing employees.

Coordinates end-to-end strategic proposal development for RFPs, RFIs, and RFQs. Analyzes requirements, develops timelines and storyboards, collaborates with sales, account management, communications, and subject matter experts, and packages high-quality final responses. Maintains proposal libraries, corporate success data, workflows, and response resources. Supports finalist presentations, new-group implementation, and client-retention activities while contributing strategy, storytelling, and sales support.

Supervises Medicare cost report audits, reviews audit work papers, cost report acceptances, desk reviews, and settlement packages for CMS compliance. Plans and budgets team assignments, evaluates results, trains audit staff, and responds to provider and CMS inquiries. The role requires auditing or accounting expertise, knowledge of Medicare reimbursement, GAAP, auditing standards, and cost accounting. Some travel between office buildings and out of town is required.

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.

Analyzes benefit plan designs, documents programming specifications, programs and audits benefit data structures and rules, and supports claims and eligibility processing. Coordinates system changes, testing, quality control, debugging, reporting, and process improvements with analysts, information systems teams, and business customers.

Supports Model Audit Rule and SOX compliance through risk assessments, process documentation, control identification and testing, deficiency evaluation, remediation oversight, and management reporting. Performs peer reviews, maintains audit workpapers and risk-control matrices, supports internal and external auditors, and assists with projects improving compliance processes. The role requires collaboration with management and auditors in a hybrid position based in Columbia, South Carolina.

Ensures the integrity and reliability of enterprise systems infrastructure through systems programming, software and hardware integration, installation, testing, maintenance, security patch evaluation, performance analysis, and disaster recovery support. The role focuses on IBM z/OS storage environments and related mainframe storage technologies, while providing technical guidance, developing standards, coordinating system changes, and resolving software issues in a 24/7 fully onsite environment.

Maintains healthcare provider files and certification data for provider directories, claims adjudication, and billing. Verifies provider information, assigns providers to networks, updates provider databases, resolves maintenance and error reports, and supports audits, quality initiatives, and mass rate updates. The role requires administrative accuracy, customer service, organizational skills, confidentiality, and familiarity with Microsoft Office. SQL and DB2 knowledge for PIMS queries is preferred.

Maintains and enhances mainframe systems software and infrastructure. Diagnoses and resolves software issues, evaluates system changes, coordinates installations and testing, manages downtime, reviews security patches and audit requirements, and provides technical guidance for enterprise technology solutions. Supports disaster recovery and system standards. The role requires extensive systems programming experience, with preferred expertise in VTAM, z/OS, mainframe communications, networking protocols, policy agents, packet tracing, Assembler, and related support products.