Location: This position is fulltime (40hours/week) MondayFriday working HYBRID at our 2401 Faraway Drive Columbia SC 29223 location You will work an 8hour shift scheduled during our business hours of 8:00AM5:00PM.

What Youll Do:

• Functions as an incharge auditor of the most complex reviews.

• Conducts onsite reviews of medical records for compliance with Corporate medical policy.

• Reviews all claim types from facility professional pharmacy and specialty pharmacy.

• Performs or supports audits on medical/pharmacy claims payments and controls and evaluates compliance with procedures laws and regulations. Develops and recommends corrected action on all identified errors.

• Engages directly with providers to obtain payment resolution and recovers funds to the Corporation while maintaining strong communication level and integrity of network contracts.

• Reports findings to and leads meetings with senior management at standing Payment Integrity Committee meeting.

• Acts as a consultant for highlevel payment and reimbursement issues.

• Provides leadership and guidance to team and assists in the development and revision of work instructions forms and procedures.

To Qualify for This Position Youll Need the Following:

• Required Education: Bachelors degree

• Degree Equivalency: 4 years job related work experience or Associates and 2 years job related experience.

• Required Work Experience: 8 years of experience with healthcare operations.

• Required Software and tools: Microsoft Office DB2 and Easytrieve

• Required Skills and Abilities:

  • Familiarity with and ability to interpret Department of Insurance guidelines and state contracts HIPAA ACA etc.

  • Comprehensive knowledge of claim adjudication procedures for hospital facility reimbursement and for provider reimbursement.

  • Familiarity interpreting provider contracts.

  • Excellent verbal and written communication.

  • Excellent organizational and analytical skills.

  • Ability to execute multiple concurrent and consecutive projects.

We Prefer That You Have the Following:

• Strong excel skills

• Highly adaptable and able to thrive in a fastpaced environment

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)

• Onsite cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

• National discounts to movies theaters zoos theme parks and more

What We Can Do for You:

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.

What to Expect Next:

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 disabilitiesand 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 pregnancyrelated 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 or callext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a casebycase basis.

We participate in EVerify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Heres moreinformation.

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