Qureos Mentor

Blue Cross Blue Shield

<div><h1 class="jobSectionHeader">Summary
 
</h1>Performs quality control audits to evaluate accuracy and effectiveness of departmental operations functions including, but not limited to, claims, membership, customer service/call center, workflow, processing support systems, procedures, documentation, etc. Identifies problems, analyzes cause and effect, and makes recommendations for improvements.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location
This role is remote full time M-F 8am-5pm.
Government Clearance : This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.
SCA Benefit Requirements : BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.
What You Will Do:
<ul><li>Conducts focused quality audits across various operations functions to ensure quality standards, procedures, and methodologies are being followed
</li><li>Documents findings of analysis and prepares recommendations for implementation of new systems, procedures, or organizational changes to reduce errors
</li><li>Identifies areas of weakness and communicates recommendations on changes and improvements to training materials
</li><li>Provides feedback to management on errors detected, ensures errors are resolved, and provides long-range solutions to causes
</li><li>Develops and implements a quality control and improvement program based on targets identified through the quality reviews
</li><li>Monitors and evaluates the implementation of corrective action plans
</li><li>Compiles data, provides feedback, and generates reports for operations and/or training areas on quality performance
</li><li>Train new employees and remains current with all guideline changes, work instructions, etc
</li><li>Writes or assists in writing desk procedures and training materials for departments.
</li><li>Provides assistance with special projects such as testing for new business implementation or system changes, reviewing change requests, interpreting department workload, statistical reports, assisting co-workers, etc.
</li></ul>To Qualify for This Position, You Will Need:
<ul><li>Required Education: High School Diploma OR equivalent
</li><li>Required Work Experience : 1 year of related claims processing, customer service, auditing, training, analysis or operations experience. 2 years of experience performing quality audits
</li><li>Required Software and tools: Microsoft Office
</li><li>Required Skills and Abilities: Strong analytical, presentation, customer service, persuasion, and organization skills. Strong business math proficiency. Able to document problems and assist in their resolution. Able to document processes and identify areas for improvement. Strong written and verbal communication skills.
</li></ul>What We Can Do for You:
<ul><li>401(k) retirement savings plan with company match
</li><li>Subsidized health plans and free vision coverage
</li><li>Life insurance
</li><li>Paid annual leave &ndash; the longer you work here, the more you earn
</li><li>Nine paid holidays
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Wellness programs and healthy lifestyle premium discount
</li><li>Tuition assistance
</li><li>Service recognition
</li><li>Incentive Plan
</li><li>Merit Plan
</li><li>Continuing education funds for additional certifications and certification renewal
</li></ul>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 a 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 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 .</div>

Senior Quality Assurance Analyst

<div><h1 class="jobSectionHeader">Summary
 
</h1>We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role as 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.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location
This position is full time (40 hours/week) Monday-Friday from 8:30am &ndash; 5:00pm EST and will be fully remote. The candidate will be asked to report on-site occasionally for trainings, meetings, or other business needs.
What You&rsquo;ll Do:
<ul><li>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.
</li><li>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).
</li><li>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.
</li><li>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.
</li><li>Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
</li></ul>To Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: Associates in a job-related field.
</li><li>Degree Equivalency: Graduate of Accredited School of Nursing or 2 years of job-related work experience.
</li><li>Required Work Experience: 2 years&rsquo; clinical experience.
</li><li>Required Skills and Abilities: Working knowledge of word processing software.
</li><li>Ability to work independently, prioritize effectively, and make sound decisions.
</li><li>Good judgment skills.
</li><li>Demonstrated customer service, organizational, and presentation skills.
</li><li>Demonstrated proficiency in typing, spelling, punctuation, and grammar skills.
</li><li>Demonstrated oral and written communication skills.
</li><li>Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills.
</li><li>Ability to handle confidential or sensitive information with discretion.
</li><li>Required Software and Tools: Microsoft Office.
</li><li>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.
</li></ul>We Prefer That You Have the Following:
<ul><li>Preferred Education: Bachelor's degree- Nursing.
</li><li>Preferred Work Experience: Work experience in healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
</li><li>Preferred Skills and Abilities: Working knowledge of spreadsheet, database software.
</li><li>Knowledge of contract language and application.
</li><li>Thorough knowledge/understanding of claims/coding analysis/requirements/processes.
</li></ul>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.
<ul><li>Subsidized health plans, dental and vision coverage
</li><li>401k retirement savings plan with company match
</li><li>Life Insurance
</li><li>Paid Time Off (PTO)
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Education Assistance
</li><li>Service Recognition
</li><li>National discounts to movies, theaters, zoos, theme parks and more
</li></ul>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 .</div>

Managed Care Coordinator I

<div><h1 class="jobSectionHeader">Summary
 
</h1>We are currently hiring for a Utilization Management Coordinator I to join BlueCross BlueShield of South Carolina. In this role as a Utilization Management Coordinator I, you will perform medical surgical/pharmacy reviews using established criteria sets and/or perform utilization management of services within the LPN/LBSW scope of practice to include but not limited to professional, durable medical equipment, home health services, and/or pharmacy requests covered under the medical plan. You will document decisions using indicated protocol sets or clinical guidelines and provide support and review of medical claims and utilization practices.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location
This position is full-time (40 hours/week) Monday-Friday from 8:30am &ndash; 5:00pm and will be remote . The candidate may be required to report on-site for occasional trainings, meetings, or other business needs.
What You&rsquo;ll Do:
<ul><li>May provide any of the following in support of utilization review practices: Performs authorization process, ensuring benefit coverage for appropriate medical/pharmacy services based on established Utilization Management guidelines and criteria. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Conducts research necessary to make thorough/accurate basis for each determination made. Supports the discharge planning process by assisting and collaborating with Managed Care Coordinators as appropriate.
</li><li>Educates internal/external customers regarding medical reviews, medical terminology, coverage determinations, coding procedures, and UM processes, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
</li><li>Completes all Required Licenses and Certificates and attends mandatory meetings. Identifies and makes referrals to appropriate area/staff (Medical Director, Subrogation, Quality of Care, Case Management, etc.).
</li></ul>To Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: Bachelors in a job-related field
</li><li>Degree Equivalency: Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
</li><li>Required Work Experience: 2 years&rsquo; working experience as LPN or LBSW.
</li><li>Required Skills and Abilities : Working knowledge of word processing software.
</li><li>Good judgment skills.
</li><li>Demonstrates effective customer service, organizational, and presentation skills.
</li><li>Analytical or critical thinking skills.
</li><li>Ability to handle confidential or sensitive information with discretion.
</li><li>Ability to operate a computer with proficient typing skills.
</li><li>Strong oral and written communication skills.
</li><li>Required Software and Tools: Microsoft Office.
</li><li>Required Licenses and Certificates : Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR active LBSW (licensed Bachelor of Social Work) in state hired.
</li></ul>We Prefer That You Have the Following:
<ul><li>Preferred Work Experience: 1 year of utilization review experience.
</li><li>Preferred Skills and Abilities: Ability to work independently, prioritize effectively, and make sound decisions. Persuasive, motivational, and influential.
</li><li>Preferred Software and Tools: Knowledge of Microsoft Excel, Access, or other database software.
</li></ul>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.
<ul><li>Subsidized health plans, dental and vision coverage
</li><li>401k retirement savings plan with company match
</li><li>Life Insurance
</li><li>Paid Time Off (PTO)
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Education Assistance
</li><li>Service Recognition
</li><li>National discounts to movies, theaters, zoos, theme parks and more
</li></ul>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 .</div>

LPN Utilization Management Coordinator I

Overview We are seeking a dynamic and detail-oriented &lt;PHONE&gt; to join our team! In this vital role, you will serve as a key point of contact, ensuring smooth communication and efficient handling of inquiries. Your energetic approach and proactive mindset will help foster positive interactions with clients, colleagues, and stakeholders. This position offers an exciting opportunity to develop your skills in a fast-paced environment while contributing to the overall success of our organization.Responsibilities<ul><li>Manage incoming calls and direct them appropriately, ensuring prompt and courteous service</li><li>Maintain accurate records of all communications and interactions for future reference</li><li>Assist with scheduling appointments, meetings, and follow-up activities to support team operations</li><li>Collaborate with team members to streamline communication processes and improve efficiency</li><li>Provide clear information to callers and visitors, addressing inquiries or escalating issues as needed</li><li>Support administrative tasks such as data entry, document preparation, and filing systems</li><li>Contribute to a positive work environment by demonstrating professionalism and enthusiasm in every interaction</li></ul>Requirements<ul><li>Excellent verbal communication skills with a friendly and energetic demeanor</li><li>Strong organizational abilities and attention to detail</li><li>Ability to multitask effectively in a busy setting while maintaining professionalism</li><li>Proficiency in basic computer applications such as MS Office Suite (Word, Excel, Outlook)</li><li>Prior experience in customer service or administrative roles is preferred but not required</li><li>Ability to work independently as well as part of a team in a fast-paced environment</li></ul>Join us if you&rsquo;re ready to bring your energy and enthusiasm into a role that makes a real difference! We value proactive individuals who thrive on building positive relationships and supporting our organization&rsquo;s success. This paid position offers an engaging work environment where your contributions are recognized and appreciated.Job Type: Full-timePay: $25.00 - $59.77 per hourWork Location: In person

12132313131

<div><h1 class="jobSectionHeader">Summary 
 
</h1><h1 class="jobSectionHeader"> 
Description 
 
</h1>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&rsquo;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 &hellip; and much more. We are one of the nation&rsquo;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: Complete Accounts Payable function including posting vouchers, check posting and coordination of payments with vendors. Obtain approvals for invoices through multiple managers, including managing the AP emails for approvals. Process EFT and check payments, including directing all debits/credits transfer to Wells Fargo, Corporate Treasury, and Misc Funding. Send notices to vendors after the advice is created. Complete monthly close journal entries associated with AP or accruals. Manage the P-card process by booking hotels, ordering items or otherwise processing payments using the company card. Reconcile the credit card statement for all of the corporate cards for CGS.
Logistics: CGS (cgsadmin.com) , one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This is a full-time position (40-hours/week) working an 8hr shift Monday-Friday within the hours of 6:00am-6:00pm central time at 26 Century Blvd Suite ST610 Nashville TN 37214 in an office environment. Hybrid/remote opportunities may be available after initial training period.
SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act ( SCA ). Under the McNamara-O'Hara Service Contract Act (SCA), employees are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.
What You&rsquo;ll Do:
<ul><li>Prepares various in-depth financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function. Ensures data is complete, accurate, and organized for processing. Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
</li><li>Completes moderately difficult to complex research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds. Resolves most questions and problems, referring most complex issues to higher levels.
</li><li>Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
</li><li>Provides other support duties related to the accounting/finance function that may include monitoring financial systems, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc. Assists less experienced accounting clerks as needed.
</li><li>Prepares journal entries and account reconciliations. Responds to telephone and written inquiries from internal and external customers to ensure accurate billing, payments and/or collections.
</li></ul>To Qualify, You&rsquo;ll Need:
<ul><li>Required Education: Bachelor's in a job-related field
</li><li>Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience
</li><li>Required Skills and Abilities: Good oral and written communication and customer service skills. Excellent organization skills and attention to detail. Strong business math skills.
</li><li>Required Software and Tools: Microsoft Office.
</li></ul>We Prefer That You Have:
<ul><li>Strong MS Office skills, and especially with Excel.
</li><li>Keen attention to detail.
</li></ul>Our comprehensive benefits package includes the following:
<ul><li>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.
</li><li>Subsidized health plans, dental and vision coverage
</li><li>401k retirement savings plan with company match
</li><li>Life Insurance
</li><li>Paid Time Off (PTO)
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Education Assistance
</li><li>Service Recognition
</li><li>National discounts to movies, theaters, zoos, theme parks and more.
</li></ul>What We Can Do for You:
<ul><li>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.
</li></ul>What to Expect Next:
<ul><li>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.
</li></ul>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 .</div>

Accounting Technician III (Accounts Payable)