Summary
 

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!

Description
 

Position Purpose:
Identify, research, and investigate providers for aberrant and abusive billing practices against the company and its subsidiaries. Analyze hospital accounting records and credit reports for overpayments and fraudulent billing to the corporation.

Logistics:
This position is a W@H position. Please note, this is subject to change based on business needs and/or employee performance.

What You’ll Do:

• Conduct onsite audits of hospitals and provider facilities to identify overpayments and compliance with government regulations, which may include Medicare Secondary Payer (MSP) regulations. Analyze provider contracts to determine the proper reimbursement of inpatient and outpatient benefit payments and calculates correct refunds.
• Perform comprehensive review and responds to complex inquiries of all varieties of provider facilities. This may include the review, trending, analysis, and executive report of all claims actions. Identify potential fraud and abuse situations and refers documented findings to appropriate area for investigation.
• Develop comprehensive financial strategies and master audit programs for hospitals and provider reviews. Conduct outreach workshops and training sessions for appropriate groups to focus on problem areas relating to government regulations and billing issues. May coordinate research and reporting functions for the MSP prepay claims department.

To Qualify for This Position, You’ll Need:

Required Education:

• Bachelor’s Degree in a job related field

Required Work Experience:

• 6 years of experience with health insurance claims and/or hospital billing procedures.

Degree Equivalency:

• Associate's degree plus 2 years of job-related work experience for a total of 8 years required experience.

OR

• 10 years of job-related work experience.

Required Skills and Abilities:

• Analyze provider contracts.
• Conduct provider compliance audits.
• Identify potential fraud situations.
• Make recommendations for corrective actions.
• Produces monthly summary reports.

What we Prefer you to have:

• Experience writing Audit reports.
• Medicare Claims Knowledge.
• Ability to read Remits and EOBs.
• Ability to hold conference calls with Senior Management both internally and externally.
• Ability to interpret and understand MSP requirements as they are found in the CMS IOMs.

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.  

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

Some states have required notifications. Here's more information. 

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. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.