Qureos Mentor

Blue Cross Blue Shield

<div><h1 class="jobSectionHeader">Summary
 
</h1>Analyzes current and proposed policies, procedures, systems, forms, and reports for the department. Analyzes existing processes and procedures to recommend operational improvement through standardization, simplification, discontinuance or other methods. May recommend installations of new systems and procedures and with implementation, instructs personnel regarding them.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Logistics: Palmetto GBA &ndash; one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. This role is located at 17 Technology Circle, Columbia, SC 29203.
<ul><li>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.
</li></ul>What You&rsquo;ll Do:
<ul><li>Analyzes data that has a vital impact on the success of the operation, program or project and that is used for developing operating strategies. Develops, maintains and reviews processes, procedures, policies and forms for the department. Identifies patterns and trends in data for business decisions by department or division leadership. Prepares materials which help explain findings such as reports, charts, visual aids, etc. Monitors departmental methods to ensure compliance with internal measures and contract/business requirements.
</li><li>Reviews items directed to management. Advises and keeps management apprised of any potential issues or items that need to be addressed. Recommends a response or solution to any issues identified or outstanding. Assists management with complex reviews such as analysis of expenditures that would help determine if process improvements, projects, or implementations are within projections. Provides periodic/consistent information to management impacted by assigned projects. Manage/relay project status, purpose, scope and timing.
</li><li>Serve as liaison between the division or department and other areas on management reports, including reports concerning workload statistics. Attends and participates in teleconferences and meetings with customers. May also serve as liaison between the area and the contractor regarding any discrepancies found in reports.
</li><li>Functions as a project leader on work teams. Assists service areas with resolving compliance issues or questions. Identify opportunities for improvement and areas/issues that can be addressed with educational initiatives. Trains staff on new initiatives.
</li><li>Identify and research discrepancies and questions related to data input based on reports. Monitors reports to assess the impact of performance on key measures.
</li></ul>To Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: Bachelor's degree.
</li><li>Required Work Experience: 4-years of data analysis or related operations experience.
</li><li>Required Skills and Abilities:
<ul><li>Strong communication, analytical, project management and organizational skills.
</li><li>Fully understands acceptable internal standards and methodologies.
</li><li>Advanced analysis skills.
</li><li>Able to identify complex problems and recommend solutions.
</li><li>Able to provide guidance and lead in developing and implementing process improvement for the department and division.
</li></ul></li><li>Required Software and Tools: Microsoft Office.
</li></ul>We Prefer That You Have the Following:
<ul><li>Preferred Education: Bachelor's degree in Business, Healthcare, or other job-related field.
</li><li>Preferred Work Experience: 4-years of healthcare or insurance data analysis experience.
</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>

Senior Operations Analyst

<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 we've been part of the national landscape for more than seven decades, 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'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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures.
Logistics: National Alliance &ndash; one of BlueCross BlueShield of South Carolina&rsquo;s subsidiary companies.
Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-4:30PM. **Hybrid/remote schedule may become available after initial training and the ability to maintain acceptable performance metrics. Due to the hybrid nature of the schedule, qualified local candidates within commuting distance of 4101 Percival Rd., Columbia, SC 29229 are encouraged to apply.
What You&rsquo;ll Do:
<ul><li>Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Verifies that claims have been keyed correctly.
</li><li>Ensures that claims are processing according to established quality and production standards. Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
</li><li>Researches and resolves claims edits and deferrals. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas. Responds to routine correspondence and completes spreadsheet if applicable.
</li></ul>T o Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: High School Diploma or equivalent
</li><li>Required Work Experience: 2 years of experience processing, researching and adjudicating claims.
</li><li>Required Skills and Abilities: Strong organizational, analytical and judgment skills. Strong oral and written communication skills. Proficient in spelling, punctuation and grammar. Proficient in basic business math. Ability to handle confidential or sensitive information with discretion.
</li><li>Required Software and Tools: Microsoft Office.
</li></ul>We Prefer That You Have the Following:
<ul><li>Preferred Work Experience: 5 years-of experience processing and adjudicating claims.
</li><li>Preferred Skills and Abilities: Strong time management skills. Knowledge of mathematical and statistical concepts.
</li><li>Preferred Software and Other Tools: Proficient in word processing and spreadsheet applications. proficient database software skills.
</li><li>Work Environment: Typical office environment.
</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 for 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>

Processor, Claims II

<div><h1 class="jobSectionHeader">Summary
 
</h1>Working at CGS Administrators
 
CGS Administrators, LLC (CGS) is part of BCBSSC&trade;'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.
 
 
Partner with Medicare, Medicaid, the Veterans Administration, and other healthcare organizations to support data management, reporting, and insightful analytical work.
 
 
Join a collaborative, people‑focused team that values positivity, support, and teamwork. Apply now and elevate your career!
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Logistics: CGS &ndash;one of BlueCross BlueShield's South Carolina subsidiary companies.
<h1 class="jobSectionHeader">Sponsorship: This position is not eligible for sponsorship now or in the future.
</h1>Work Environment :
<ul><li>Typical office environment. Some travel between buildings and out of town.
</li></ul>Position Purpose:
Creates and analyzes reports to support operations. Ensures correctness of analysis, and reports findings in a concise manner to senior management. Directly responsible for accuracy of data as financial and operational decisions are made based on the data provided.
What you&rsquo;ll do :
<ul><li>Generates internal and external reports to support management in determining productivity and efficiencies of programs or operational processes. Revises existing reports and develops new reports based on changing methodologies.
</li><li>Analyzes reports to ensure accuracy and quality. Tracks and verifies all reporting statistics.
</li><li>Communicates and trains employees and managers on the complex database programs used to generate analytical data.
</li><li>Designs, codes, and maintains complex database programs for the extraction and analysis of data to support financial and operational decisions.
</li></ul>To Qualify for This Position, You&rsquo;ll Need:
Required Education:
<ul><li>Bachelor's in a job-related field
</li></ul>Degree Equivalency:
<ul><li>Associates degree plus an extra 2 years job-related experience for a total of 6 years of required work experience (see &quot;required work experience&quot;)
</li></ul>OR
<ul><li>8 total years required work experience.
</li></ul>Required Work Experience:
<ul><li>4 Years Research and analysis experience.
</li></ul>Required Skills and Abilities:
<ul><li>Strong organizational, customer service, communications, and analytical skills.
</li><li>Advanced experience using complex mathematical calculations and understand mathematical and statistical concepts.
</li><li>Knowledge of relevant computer support systems.
</li><li>Ability to train subordinate staff including provide assistance/guidance to staff in design/execution of reporting needs.
</li><li>Proven experience with report writing and technical requirements analysis, data and business process modeling/mapping, and methodology development.
</li><li>Strong understanding of relational database structures, theories, principles, and practices.
</li></ul>Required Software and Other Tools:
<ul><li>Advanced knowledge of Microsoft Office. Knowledge of programming languages across various software platforms, using DB2, SQL, and/or relational databases.
</li><li>Knowledge of tools such as Visual Basic and Macros useful in automating reporting processes.
</li></ul>We Prefer That You Have:
<div>&bull; Advanced SQL skills and experience with cloud data warehouse environments
 
<ul><li>Proficiency with Python or R for analytics
</li><li>Experience with modern BI tools (e.g., Power BI, Tableau)
</li><li>Understanding of ETL/ELT processes and data pipeline concepts
</li><li>Familiarity with data governance, data quality practices, and version control (Git)
</li><li>Strong data storytelling and stakeholder communication skills
</li><li>Ability to mentor junior analysts and support analytical standards
</li></ul></div>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:
<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>Nine paid holidays
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Wellness program and healthy lifestyle premium discount
</li><li>Tuition assistance
</li><li>Service recognition
</li><li>Employee Assistance
</li><li>Discounts to movies, theaters, zoos, theme parks and more
</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 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 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>

Data Analyst III - CGS Administrators, LLC

<div>This role leads and supports quality strategy and operations initiatives focused on clinical data, HEDIS processes, and performance improvement. Responsibilities include managing projects related to data integration, HEDIS abstraction, NCQA audit support, clinical reporting, and the implementation and adoption of clinical and reporting applications. The role drives FEP&rsquo;s annual HEDIS submissions, contributes to strategies to improve measure performance, collaborates with technical, analytic, and clinical partners, and delivers clear, targeted communication to diverse audiences. Success requires clinical expertise, strong organizational and management skills, and a proactive, curiosity driven approach to learning and new responsibilities.<div></div><ul><li>
Leadership and Initiative Management: Manages and provides leadership for various initiatives, including clinical data integration and governance, with a focus on quality improvement and care coordination.</li><li>
Project and Data Management: Oversees and significantly contributes to the execution of complex, cross-functional projects. Manages the collection, analysis, and synthesis of data, utilizing various research methodologies and data models.</li><li>
Stakeholder Engagement: Represents the department in internal and external groups, conferences, and meetings. Builds and maintains relationships with internal and external business partners, serving as a liaison among stakeholders.</li><li>
Process Improvement and Best Practices: Conducts analyses of best practices in the health industry, identifies issues, and recommends initiatives to address data quality and integrity. Develops strategies and recommendations to meet objectives and may lead or participate in implementation teams.</li><li>
Technical and Business Liaison: Acts as a liaison between IT and the business, understanding technical aspects of solutions, business systems, and software. Provides oversight and guidance in resolving complex issues and supports division budget and objectives.</li></ul><div></div><div>
The posting range for this position is: 
$103,677.00-$149,129.62 
 
Qualifications: 
 
Education</div><ul><li>
Required Bachelor's Degree or equivalent work experience</li></ul><div>
Experience</div><ul><li>
Required 5+ Years experience within a health plan or health services delivery setting with experience in clinical quality, operations, claims processing, provider contracting, research, analytics, and/or healthcare informatics</li></ul><div> 
Knowledge Skills and Abilities</div><ul><li>
Ability to build consensus for business results in a decentralized decision-making structure, relying on excellent process management and conflict management skills including advanced time and resource management skills.</li><li>
Excellent communication (written and oral) and interpersonal skills with an ability to communicate to small and/or large audiences (both internal and external to BCBSA)</li><li>
Advanced analytic skills with the ability to analyze and interpret data through complex analysis.</li><li>
Demonstrate curiosity and determination in pursuing complex and innovative approaches to data analyses.</li><li>
Knowledge of SAS, SQL, Cognos, or MCSource.</li></ul><div></div><div> 
Certifications &amp; Licenses</div><div></div><ul><li>
Preferred: CHC - Certified Healthcare Compliance</li></ul><div></div><ul><li>
Extra Posting Information:</li><li><div>
A minimum of five years experience within a health plan or health services delivery setting with experience in clinical quality, operations, claims processing, provider contracting, research, analytics, and/or healthcare informatics.</div></li><li><div>
PC experience using database programs, spreadsheets, and word processing, including all components of MS Office (particularly MS Excel and MS Access).Experience in consulting on and implementing cost-effective care management programs. Experience working with large data repositories and/or relational databases, as well as, experience with data mining. Experience with predictive modeling and risk stratification, including a working knowledge of quantitative analysis, disease prevalence, ROI, outcome measurements, benchmarks, trends and outliers.</div></li></ul><div></div><div>
#LI-Hybrid</div><div></div><div><div>
The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate&rsquo;s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay.</div></div><div><div>
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees.</div></div><div></div><div><div>
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.</div></div></div><div></div>

Clinical Operations Senior Analyst - Quality Improvement Operations

<div><h1 class="jobSectionHeader">Summary
 
</h1>Performs non-medical reviews and processes redetermination letters.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location : This position is hybrid schedule 3 days onsite reporting at 26 Century Blvd Suite ST610Nashville, TN 37214 and two days remote, this is a full time role (40 hours/week) Monday-Friday.
As an Appeals Specialist, you'll be at the forefront of patient advocacy, reviewing and managing redeterminations and first-level appeals with precision and care. Your daily work involves analyzing comprehensive documentation, identifying missing information, ensuring timely processing, and making decisions that directly impact healthcare outcomes. You'll review cases thoroughly, update records meticulously, and communicate clear decisions through professional correspondence. This is more than data entry&mdash;you're the critical checkpoint that ensures fair healthcare decisions are made, and patients receive the answers they deserve. Work independently on a computer-based role (no phones required) and take pride in knowing your attention to detail and thoroughness makes a tangible difference in people's lives every single day.
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>Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy
</li><li>Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools
</li><li>Updates letters and documents within the department when necessary
</li><li>May gather and prepare documentation for legal inquiries and administrative requests
</li></ul>To Qualify for This Position, You Will Need:
<ul><li>Required Education : High school diploma or equivalent
</li><li>Required work experience: 2 years in a job-related field
</li><li>Required Skills and abilities : Demonstrated proficiency in word processing and spreadsheet software, excellent organizational, customer-service, and written and oral communications skills, good judgment, proficiency in spelling, punctuation and grammar, microsoft Office 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>

Appeals Specialist