Operational Cost Containment Insurance Manager (Medicaid)

Logistics: This role is onsite at the Atrium Building - 2401 Faraway Drive, Columbia, SC.

We are interested in every qualified candidate who is eligible to work in the United States. However, we are not able to sponsor visas for this position.

What You'll Do:

• Direct the review and audit of claims and membership to identify lost revenue, overpayments, and fraud/abuse patterns. Design and implement corrective procedures, work with overpayment staff to make recoveries, and identify proactive mechanisms for avoiding overpayments. Primary person responsible for generating ideas and initiatives focused on overpayment and recovery. Responsible for overseeing and managing overpayment, recovery, or DRG validation vendors. Direct Operations staff in corrective actions designed to eliminate operational errors, which result in inaccurate claims payments.

• Analyze data requirements of CHC and assist in developing and implementing programs based on analysis. Direct Operations analyst in developing data queries and reports used to identify payment patterns, payment problems, and fraud. Responsible for ongoing review and maintenance of corrective actions.

• Review and analyze private sector claims and healthcare practices to determine healthcare trends and payment patterns affecting the corporation's overall underwriting/actuarial goals. Utilize data to formulate actions to reduce costs. Include analyzing data from multiple departments to assist in meeting corporate cost containment objectives. Responsible for meeting savings goals resulting from audits. Develop and maintain PC databases and spreadsheets to collect and report data. This includes oversight of extracting, analyzing, and joining data from the mainframe, PC, and other vendor databases

• Ensure that quality, professional management-level reports are prepared based on analysis of available data. Develop and implement action plans to aid in controlling costs and recovering overpayments. Assume responsibility for any corporate tasks assigned by the Executive vice president. Perform special reviews and research as directed by senior management.

To Qualify for This Position, You'll Need the Following:

• Required Education: Bachelors in a job-related field.

• Degree Equivalency: Four (4) years job related work experience or Associate's and 2 years job related work experience (Equivalency not applicable for the Celerian Group, Bachelor's degree required).

• Required Experience: Four (4) years of healthcare industry finance and deliver areas including executive and institutional providers. Four (4) years of experience managing or leading staff that perform data management and analysis functions.

• Required Software and tools: Microsoft Office. Basic knowledge of DB2.

• Required Skills and Abilities: Knowledge of managed care principles, insurance, and reimbursement methodologies. Working knowledge of insurance contracts, claims, membership, and care management. Understanding of healthcare delivery and reimbursement systems. Excellent verbal and written communication skills. Ability to organize, prioritize, and delegate department functions. Contracts, organizational structures, and administrative procedures. Ability to make recommendations for corrective action.

We Prefer That You Have The Following:

• Experience with hospital or insurance billing strongly preferred. Previous experience in data manipulation related to claims and membership.

• Experience with data manipulation through use of analysis databases, such as SAS, SPSS, or similar analytical data repositories.

• Experience with CMS (Centers for Medicare & Medicaid Services) and SCDHHS (South Carolina Department of Health & Human Services investigations.

• Working knowledge of industry claims adjudication practices, processes, and payment policies.

• Background in CPT-4, ICD-9 medical terminology. Working knowledge of DRG's coding processes and/or practices. Understanding of healthcare delivery systems.

• Analytical skills necessary to identify billing/coding problems, practice patterns, and administration, to make recommendations for corrective measures.

• Ability to organize priorities, delegate department functions and lead a team independently.

• Advanced training in database use.

• Preferred Certifications: CFE or AFHI certification

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

• Tuition Assistance

• Service Recognition

• Employee Assistance

• 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 conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the required qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.