60% Completes risk assessment of each member at initial enrollment and on an on-going basis when a material diagnosis or family status change occurs. Review new member documentation to ensure all necessary information has been provided in order to calculate risk score. Evaluate prescription history and request health surveys to be completed as needed. Develop forecasting for next plan year to address each member's potential risk. Record forecasting within system to create risk leveling and to forward as appropriate to Healthcare Services for review.
Completes action requests and other internal and external requests for information pertinent to members.
Serves as liaison to district offices, other departments, and agents concerning any issues that may arise.
Completes analysis of Grandfathered group business, large group new business, and alternate funding arrangements.
Reviews and approves or rejects applications for retroactive requests.
Required Education: Bachelor's in a job related field
Required Work Experience: 2 years medical risk assessment, risk management, data analysis, or other job related work experience.
Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience.
Required Skills and Abilities: Strong analytical, decision-making, communications, customer service, and advanced math skills. Excellent organizational skills. Proficient spelling, grammar, and punctuation. Knowledge of mathematical or statistical concepts. Ability to use complex mathematical calculations. Ability to handle confidential or sensitive information with discretion. Extensive knowledge of medical coding and its application.
Software and Other Tools: Standard office equipment. Knowledge of word processing and spreadsheet software.
Preferred Licenses and Certificates: Certified Medical Coder.
Work Environment: Typical office environment.
This is a work from home opportunity within South Carolina.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
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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.
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