Claims Review Coordinator Jobs

Summary

Description

Summary

BlueChoice Health Plan is a wholly owned subsidiary of BlueCross BlueShield of South Carolina, the largest health insurance company in the Palmetto State. We offer and excellent working environment, with quality benefits.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

This role act as liaison for the department for priority cases, reviews and inquiries. Lead/assist staff on processing appeals and ensure the quality and timeliness of their work efforts. Handle complex appeals processing and provide training as needed.

Logistics

This is a full-time position working (40-hours/week) Monday-Friday between the hours of 7:00 am - 5:00 pm on-site at 4101 Percival Rd. Columbia SC in an office environment. Training will be held 4 to 6 weeks with potential to work from home after training.

What You'll Do

• Review and assess requests for external review of second level appeals, in coordination with Medical Director, to determine eligibility of the claim for external review as well as appropriate documentation to be provided to the Independent Review Organization (IRO). Once the IRO has reviewed the claim, ensure the claim is processed appropriately, according to their determination.
• Distribute work to appeals staff and monitor the status of pending appeals. Assist staff with questions on processing appeals, ensuring communication to members and/or providers meet state and federal mandates as well as company/department guidelines and standards. Provides quality checking of appeals staff work. Provide training on claims appeals/reconsiderations as needed. Develop or assist in developing training materials and procedures with attention to changes in policies and process improvements.
• Communicate with members, providers and/or external organizations regarding appeals status or questions. Address critical inquiries from senior management through research.
• Handle the processing of difficult appeals and serve as liaison to areas such as Medical Affairs, Claims, Marketing, Legal, and other Blue plans. Determine the files and/or key documentation that are relevant and need to be provided for possible litigation cases, priority reviews and/or complex inquiries.
• Responsible for area record keeping and/or reporting, which is provided to management. May also be responsible for system testing/coordination for area when process enhancements are made to the system.

To Qualify For This Position, You'll Need

• Processes appeals
• Documents appeals resolution
• Supports second level reviews
• 3 years of experience processing, researching and adjudicating claims.
• Associate Degree or 2 years of job related work experience.
• Works claims caseloads
• Communicates appeals status

What We Can Do For You

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.

• 401K retirement savings plan with company match
• Wellness program and healthy lifestyle premium discount
• Life Insurance
• Subsidized health plans, dental and vision coverage
• On-site cafeterias and fitness centers in major locations
• Service recognition
• Paid Time Off (PTO)
• Tuition assistance
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

What To Expect Next

After submitting your application, our recruiting team members will review your resume to ensure your meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. If the qualifications required proof of semester hours, please attach your transcript to your application.

Management will be conducting interviews with the most qualified candidates, with prioritization give to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.