Specialist, Lead Cost Containment Position Available In Richland, South Carolina

Summary Position Purpose:

The primary objective of this position is to lead investigations/audits to validate accuracy of charges submitted to the corporation for payment for the purpose of cost containment. Analyzes statistical data findings to detect overpayments from claims processing and initiates refund procedures to maintain cost effective processing and premium billing.

Description Location:

This position is full-time (40-hours/week) Monday-Friday working HYBRID at our 2401 Faraway Drive, Columbia, SC 29223 location You will work an 8-hour shift scheduled during our business hours of 8:00AM-5:00PM.

What You’ll Do:

Functions as an in-charge auditor of the most complex reviews. Conducts on-site 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 high-level 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, You’ll Need the

Following:

Required Education:

Bachelor’s degree

Degree Equivalency:

4 years job related work experience or Associate’s 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 fast-paced 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) 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. 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 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. If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit. Welcome Here’s Your Smart Career Move 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. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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! Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us If you’re ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!