BlueCross BlueShield of South Carolina

Provided housekeeping, caregiving, and childcare services, including cleaning, bathing, and meal preparation. | High school diploma with extensive caregiving and housekeeping experience, no formal healthcare or nursing credentials. | Summary We are currently hiring for a part-time RN Managed Care Coordinator to join BlueCross BlueShield of South Carolina. In this role as a part-time RN Managed Care Coordinator I, you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Description Location: This position is part-time (30 hours/week) Monday-Friday from 8:30am-5:00pm EST and will be fully remote. The candidate will be required to report on-site for trainings, meetings, or other business needs. What You’ll Do: • Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. • Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). • Provides patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. • Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. • Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. To Qualify for This Position, You'll Need the Following: • Required Education: Associates in a job-related field. • Degree Equivalency: Graduate of Accredited School of Nursing or 2 years of job-related work experience. • Required Work Experience: 2 years’ clinical experience. • Required Skills and Abilities: Working knowledge of word processing software. • Ability to work independently, prioritize effectively, and make sound decisions. • Good judgment skills. • Demonstrated customer service, organizational, and presentation skills. • Demonstrated proficiency in typing, spelling, punctuation, and grammar skills. • Demonstrated oral and written communication skills. • Ability to persuade, negotiate, or influence others. • Analytical or critical thinking skills. • Ability to handle confidential or sensitive information with discretion. • Required Software and Tools: Microsoft Office. • Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire. What We Prefer You to Have: • Preferred Experience: One year of Utilization Review experience. • Previous experience in DME, Home Health, and/or Hospice cases • Preferred Skills & Abilities: Ability to work independently, prioritize effectively, and make sound decisions. Ability to be persuasive, motivational, and influential. Our Comprehensive Benefits Package Includes the Following: We offer our part-time employee’s great benefits and rewards. You will be eligible to participate in health insurance at the end of the ACA period and will be eligible to enroll in a 401k plan if you are over the age of 21. 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. 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 disabilities and 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 pregnancy-related 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 mycareer.help@bcbssc.com or call 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

Manage multiple concurrent IT projects ensuring delivery on time, within budget, and according to scope while coordinating resources and communicating with stakeholders. | Bachelor's degree or equivalent experience, 5+ years IT leadership with 2+ years managing multiple project teams, PMP certification preferred, strong communication and project management skills, and proficiency with Microsoft Office and project management tools. | Summary Job Description Summary CGS Administrators, LLC (CGS) is part of BCBSSC 's Celerian Group of companies and provides a variety of services for Medicare beneficiaries, healthcare providers, and medical equipment suppliers in 38 states, supporting the needs of over 8.7 million Medicare beneficiaries and 103,000 healthcare professionals nationwide. Position Purpose: Responsible for overall coordination, status reporting, and stability of project-oriented work efforts. Responsible for moderate number of work efforts simultaneously that vary from a smaller to a moderate scale, with smaller number of hours to moderate number of hours, and with moderate system impacts and moderate scope and complexity. Adheres to project management processes and methodologies to ensure projects are delivered on time, within budgeted hours, adheres to high quality standards, and meets ISSM expectations. Monitors project plans, assignments and work efforts on a daily basis. Ensures resource needs are assigned appropriately and escalates functional, quality, timeline issues. Tracks key project milestones and adjusts project plans to meet the needs of work effort. Responsible for leading the project from inception to final business acceptance and implementation. Description Logistics: CGS -one of BlueCross BlueShield's South Carolina subsidiary companies. Work Environment : • Fast paced, dynamic environment which may require action and response 24X7 to support the technical business needs of the customer and where one must be flexible to changing priorities. What you'll do: • Develops and monitors project plans, risk management plans, and project documentation from scope to post implementation. Ensures project documentation and deliverables are complete, on budget, within scope, and in accordance with standards. • Identifies items that impact the scope, budget, risk, and resources of the work effort. Monitors resource requirements based on project specifications. Ensures resources are assigned to meet project objectives while managing project hours budgeted. • Responsible for the development, execution, and maintenance of project communications. Facilitates effective communications between all parties involved in the project and/or work efforts. This will include meetings, correspondence, status reports and other documentation. • Identifies the impact of issues arising from the work efforts and/or resource requirements. Manages the project issues throughout the project life cycle. Communicates the implications of changes to the project scope with senior management and other appropriate parties. • Responsible for ensuring all work efforts have appropriate documentation for audit purposes utilizing project methodology standards in accordance with the ISSM. To Qualify for This Position, You'll Need: Required Education: • Bachelor's degree Degree Equivalency: • Associates degree plus an extra 2 years job-related experience for a total of 7 years of required work experience (see "required work experience") OR • 9 total years required work experience. Required Work Experience: • 5 years IT experience in a leadership capacity, including 2 years experience leading two or more concurrent project teams. • Completion of the BCBSSC Training Program for Project Management may substitute for one year of experience. Require Skills and Abilities: • Excellent communications (verbal and written) skills with assertive yet customer-focused style. • Advanced leadership skills in a team or project environment. • Excellent problem solving and conflict management/resolution skills. • Advanced analytical and organizational skills with attention to detail. • Strong understanding of project management principles and methodologies, information systems, business processes, and the key drivers and measures of success for the business unit and the organization. • Advanced competency in management of resources to meet goals and multiple projects. • Strong ability to lead multiple multidiscipline, high-performance work teams throughout project life cycle. • Strong ability to negotiate terms and scope of work documents. • Advanced ability to prepare and present formal presentations. • Ability to manage all phases of work effort from inception to completion. • Effective strategic thinking skills. • Demonstrated proficiency in conducting analysis of project triple constraints. Required Software and Tools: • Advanced knowledge of Microsoft Office and project management tools. We Prefer That You Have: • Active PMP Certification. • Experience with agile and waterfall methodologies. • IT Project Management Healthcare (Medicare/Medicaid) experience. • Proficiency in Microsoft Project and schedule management. 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 access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. Our comprehensive benefits package includes: • 401(k) retirement savings plan with company match • Subsidized health plans and free vision coverage • Life insurance • Paid annual leave - the longer you work here, the more you earn • Nine paid holidays • On-site cafeterias and fitness centers in major locations • Wellness programs and a healthy lifestyle premium discount • Tuition assistance • Service recognition 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 qualify with prioritization given to those candidates who demonstrate the preferred 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 disabilities and 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 pregnancy-related 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 call , 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information . Some states have required notifications. Here's more information .

Provide personalized health coaching and education to members remotely, assess needs, develop and implement action plans, and promote health program enrollment. | Associate degree or equivalent experience in health-related field, 3+ years professional health and wellness experience, proficiency in Microsoft Office, and certification in health coaching within 4 years. | Summary Provide support to members for disease prevention and healthy promotion. Empower members to achieve optimal health and wellness by providing personalized guidance, education, and support. This role collaborates with individuals to set and reach health goals, navigate the healthcare system, and make informed decisions about their well-being within the context of their health plan benefits Description Logistics: This is a full-time remote position based in South Carolina, open only to candidates residing in the state. What You'll Do: Assess for needs related to a member's chronic condition, clinical risk and readiness for change via company needs questionnaire. Based on the needs assessment, complete and coordinate action plans in cooperation with members, then implement plans to include member goals. Provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to elicit behavior change and increase member program engagement. Participates in patient education with members and providers regarding the member's condition and available benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in health and chronic condition management programs. Provides appropriate communications (written, telephone) regarding member conditions to both health care providers and members. Participates in data collection/input into system for clinical information flow. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Maintains current knowledge of network status of all service providers to educate members on care they may receive related to their chronic condition(s). Assists members with referrals to appropriate internal support areas to ensure proper processing of authorized or unauthorized services, as needed. Required Education: Associate's in job related field Degree Equivalency: Graduate of Accredited School of Nursing or graduate of a health-related degree or 2 years job related work experience Required work experience: 3 years of professional health and wellness experience Required skills and abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Software and other tools: Microsoft Office Licenses and Certifications: Within 4 years of hire, must get certification in health coaching (ex: National Board Certified Health and Wellness Coach). Preferred Education: Bachelor's degree in health-related field (e.g. Nursing, Social Work, Health Ed, Wellness, Health Promotion, Behavioral Health) Preferred Work experience: 5 years - healthcare management Preferred Specialized Training: Health Coaching Certification Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Work environment: Typical office environment. Employee may work form one's/out of one's home. May involve some travel within one's community. Onsite training may be required depending on the employee's performance and development needs. 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 disabilities and 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 pregnancy-related 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 mycareer.help@bcbssc.com or call 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

Manage and complete sales proposals, RFI/RFPs, analyze market and product data, and provide detailed reports and recommendations to management. | Bachelor's degree or equivalent experience with 3 years marketing support or sales experience including 2 years in market research or data analysis, preferably with Stop Loss, Smartsheet, and CRM Microsoft Dynamic 365 experience. | Summary Position is responsible for handling new sales proposals, quotes, shopping stop loss for new prospects and for completing full RFI/RFPs for PAI. Conducts market, product, and competitor research to be used in the development of new products. Collects and analyzes market data and provides management with reports. Position is responsible for handling new sales proposals, quotes, shopping stop loss for new prospects and for completing full RFI/RFPs for PAI. Experience with Stop Loss, Smartsheet and CRM Microsoft Dynamic 365 strongly preferred. Description Location: Hybrid, Onsite or Remote. This position is full-time (40-hours/week) Monday-Friday. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. What You'll Do • Completes and issues all RFPS/RFIS from agents, brokers, and consultants. Ensures that proposal responses are accurate, consistent and responsive and promotes the advantages of our products and services. • Retrieves information from all functional areas of the health plan and develops/maintains/updates database for these proposal databases. • Collects/analyzes statistical data regarding proposal activity, and existing/potential products and markets. Designs/prepares/generates and maintains reports that utilizes data to forecast future market conditions and customer preferences. Provides management with detailed reports and makes recommendations for improvement. Required Education • Bachelor's Degree Equivalency • 4 years job related work experience or Associate's and 2 years job related work experience. Required Work Experience • 3 years marketing support and/or sales. 2 of the 3 years must have been in market research or data analysis. We Prefer You To Have The Following • Stop loss experience • CRM Microsoft Dynamic 365 experience • Smartsheet experience 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) • On-site 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. 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 disabilities and 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 pregnancy-related 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 mycareer.help@bcbssc.com or call 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.