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Administer operational activities such as prepare and maintain records associated with premium collection, enrollment data and reconciliations of cash receipts. Collect and verify census enrollments and apply cash receipts in accordance with established guidelines and procedures. Follow up/investigate census and premium discrepancies, request additional information from administrators, and generat
Posted 1 day ago
Responsible for completing cost report reopenings within established timeframes and ensuring that the quality of our work meets CMS expectations. Reopenings include review of various provider types and issues related to the Medicare cost report. Description 40% Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities
Posted 1 day ago
Responsible for moderately complex accounting activities relating to the maintenance of a complete and accurate general ledger and/or the resultant managerial reports and/or financial statements. Description 30% Reconciles assigned general ledger accounts of routine to moderate complexity. Initiates and/or processes journal entries into various accounts. Performs reviews of various systems activ
Posted 1 day ago
Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Performs research as needed to resolve inquiries. Description 65% Ensures effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk in inquiries. Accurately documents inquiries. 15% Initiates or processes adjustments or performs other research as needed t
Posted 1 day ago
Monitor and/or reconcile assigned general ledger accounts of a complex nature, process complex accounting activity, resolve variances, and/or document procedures to ensure accuracy of accounting information and/or financial reports, and/or compliance with established rules and/or regulations. Provide functional advice and/or training to less experienced accountants. Description 30% Prepares dail
Posted 1 day ago
Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities. Description 70% Manages the medical review process. Maintains a well trained staff. Develops/implements medical review strategy wit
Posted 1 day ago
Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members. Description 70% Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system a
Posted 1 day ago
Responsible for submitting stop loss claim packets and responding to any requests for additional information. Additionally, the claims must be tracked and monitored. Complex analysis is performed and queries are generated to file and validate the claim submissions. Description 25% Prepare and file 50% and 100% stop loss claim packets. Run queries, compile eligibility data and submit claim packet
Posted 1 day ago
Responsible for the supervision and maintenance of the daily functions of Utilization Review/Review Nurses, Case Management, and/or Medical Review staff and specialty programs. Ensures appropriate levels of healthcare services are provided. Description 60% Manages day to day activities for assigned staff. Identifies training needs and verifies accuracy and timeliness of workflow functions. 20% S
Posted 1 day ago
Responsible for the supervision and maintenance of the daily functions of Utilization Review/Review Nurses, Case Management, and/or Medical Review staff and specialty programs. Ensures appropriate levels of healthcare services are provided. Description 60% Manages day to day activities for assigned staff. Identifies training needs and verifies accuracy and timeliness of workflow functions. 20% S
Posted 1 day ago
Leads corporate distribution systems, general agents, brokers, and other market support personnel. Responsible for planning, product development, marketing services, production and profitability for as few as two states to regions with as many as ten states. Customarily and regularly engaged in outside sales. Description 25% Leads, markets, recruits, and motivates general agents, brokers, and ot
Posted 1 day ago
BlueCross BlueShield of South Carolina
- Baltimore, MD / Philadelphia, PA / Wilmington, DE / 2 more...
Leads corporate distribution systems, general agents, brokers, and other market support personnel. Responsible for planning, product development, marketing services, production and profitability for as few as two states to regions with as many as ten states. Customarily and regularly engaged in outside sales. Description 25% Leads, markets, recruits, and motivates general agents, brokers, and ot
Posted 1 day ago
Leads corporate distribution systems, general agents, brokers, and other market support personnel. Responsible for planning, product development, marketing services, production and profitability for as few as two states to regions with as many as ten states. Customarily and regularly engaged in outside sales. Description 25% Leads, markets, recruits, and motivates general agents, brokers, and ot
Posted 1 day ago
BlueCross BlueShield of South Carolina
- Springfield, IL / Columbia, SC / Charleston, SC / 1 more...
Responsible for assisting in the execution of financial, compliance, and operational audits including evaluation of internal controls. Audits the activity of various departments and providers for compliance with plans, policies, and procedures prescribed by management. Reviews assigned portions of audit programs, determines compliance with policies and procedures, recommends corrective action plan
Posted 1 day ago
Provides depth of pharmacy underwriting capabilities and increases capacity to build and maintain financial models, plan design and pricing strategies and support trend analysis for self funded clients. Assists management by measuring financial risk and performance at the client level and the line of business level. Reviews information and data and makes recommendation for pharmacy cost structure/
Posted 1 day ago
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