Interpret medical rules, regulations, fee schedules, and edits that payers post.
Understand and manipulate payer data to build federal, state, and commercial coding and financial tables.
Maximize the efficiency and use of product solutions by properly maintaining payer specific edits.
Experian is a global data and technology company, powering opportunities for people and businesses around the world. They operate across a range of markets and have an amazing team of 25,200 people in 32 countries.
Lead business configuration validation for AWD changes to ensure workflows, routing, and rules align with approved requirements.
Perform data validation and troubleshooting to investigate issues and support timely defect resolution.
Contribute to process improvement and automation by recommending configuration changes that improve efficiency and user experience.
Nationwide is a Fortune 100 insurance and financial services company with nearly $70 billion in annual sales, protecting people, businesses, and futures since 1926. With a caring culture and thousands of associates, it has been named one of the Fortune 100 Best Companies To Work For.
Process assigned claims based on client-specified guidelines.
Meet productivity targets and procedural accuracy standards.
Mentor junior team members and collaborate on special projects.
UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. With a global presence and over 4000 employees, they are dedicated to simplicity, honesty, and leadership.
Responsible for processing insurance claims accurately and efficiently.
Analyze claim data to identify trends, errors, and potential irregularities.
Serve as a liaison between departments to support seamless claims resolution and continuous process improvement.
Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults. They are a fast-growing company serving over 200,000 seniors in 1,500+ communities across 32 states.
Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
Follows established policies and procedures to pay, pend for additional information, or deny claims.
Accountable to meet and maintain established department production and quality standards.
Evry Health is on a mission to bring humanity to health insurance by expanding benefits, increasing access and transparency, and featuring a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Develop, configure, and maintain healthcare plan designs and benefit configurations in various systems.
Perform comprehensive testing of plan configurations to ensure accurate and efficient claims adjudication.
Work closely with internal and external stakeholders to gather requirements and ensure plan configurations meet organizational and client needs.
Point C is a national third-party administrator (TPA) that delivers customized self-funded benefit programs. We are a mission-driven company with a focus on innovative cost containment strategies.
Own your queue end-to-end: respond to member inquiries within 1 business day, keep cases moving, and provide weekly updates.
Resolve eligibility issues, review bills and claims for accuracy, and answer benefits coverage questions.
Navigate carrier escalations, handle app and access issues, and contribute to product and process improvements.
Nava combines deep benefits expertise with technology to deliver a modern, transparent healthcare experience for employers. Backed by leading investors, it is a fast-growing benefits brokerage with a small, tight-knit team that values ownership and professionalism.
Facilitate client calls related to contracting and payer enrollments.
Run and analyze client KPIs, providing regular reports.
Manage the full contracting and payer enrollment process.
Experity transforms on-demand healthcare across the U.S. by empowering urgent care clinics with industry-leading software. The company fosters a team-first culture with opportunities for flexible work and career development.
Serve as the main point of contact for providers, resolving escalated issues and maintaining positive relationships.
Manage internal projects to improve provider experience, including education on best practices and policies.
Use data analysis and tools like Excel and Salesforce to investigate issues and reduce provider abrasion.
Clover Health provides high-quality, affordable healthcare plans for America's seniors by leveraging data and technology through the Clover Assistant. The company is a mission-driven, remote-first organization with a focus on diversity and inclusion, employing a team of passionate professionals.
Provides tactical implementation support and configuration expertise through ticket management, system configuration, and quality assurance activities.
Manages ticket triage, resolution, and cross-functional issue escalation using JIRA and internal tracking systems.
Performs system configurations, supports technical integrations, and conducts quality assurance and testing activities.
Included Health is a healthcare company delivering integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person in every community, offering care guidance, advocacy, and access to personalized virtual and in-person care.
Serve as the primary contact for CM/UM programs and operational questions related to the MyCare Platform.
Build relationships with provider offices through outreach and timely follow-up, resolving issues within defined turnaround times.
Educate providers on submission requirements, documentation, timelines, and available CM/UM resources.
Personify Health created a personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while improving health outcomes.
Manage insurance account workflows and ensure accurate resolution of billing and reimbursement issues.
Investigate, resolve, and appeal insurance denials while documenting actions in compliance with standards.
Monitor aged accounts receivable and prioritize workloads to optimize collections and reduce outstanding balances.
Our partner is a healthcare services organization focused on revenue cycle management. They offer a collaborative and mission-driven environment with a comprehensive benefits package.
Analyze and process workers compensation lost-time claims, investigating to determine benefits and exposure.
Negotiate settlement of claims within designated authority and communicate with claimants and clients.
Report claims to excess carrier and respond to requests in a professional and timely manner.
Sedgwick is the world’s leading risk and claims administration partner, helping clients navigate the unexpected with advanced AI-enabled technology. With over 33,000 colleagues and 10,000 clients across 80 countries, it offers a caring culture that values work-life balance and professional growth.
Troubleshoot complex product and technical issues to determine severity and scope.
Manage escalated issues from Customer Support, Account Management, and Implementation teams.
Maintain customer ownership and leverage CRM tools like Salesforce to resolve inquiries.
Experian is a global data and technology company that powers opportunities for people and businesses worldwide. With 23,300 employees across 32 countries, we are a FTSE 100 company committed to innovation and inclusion.
Provide clinical leadership and subject-matter expertise to support analysis and configuration of medical policy content within claims processing systems.
Ensure accurate implementation of medical policies, review criteria, and authorization requirements while maintaining system infrastructure integrity.
Serve as an expert resource for medical policy configuration and PGE coding, mentoring Coding Specialists and providing training to operational partners.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota. We are motivated by the well-being of our members, not profits, and we are committed to sustainability and innovation.
Handle provider inquiries through multiple channels with accuracy and precision.
Establish and maintain positive relationships with providers on behalf of the company.
Complete ongoing training to stay abreast of products, services, and policy changes.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association offering health insurance. It is consistently voted one of the "Best Places to Work in PA" and values employee growth and community involvement.
Put the employee experience first by designing and administering health, retirement, and wellbeing programs with a focus on clarity and accessibility.
Champion employee understanding and adoption of benefits through thoughtful communication, data-driven insights, and strategic partnerships.
Act as a trusted advisor to HR colleagues and employees, bringing empathy and strong problem-solving skills to complex situations.
Blue Cross & Blue Shield of Rhode Island is a health insurance provider dedicated to serving Rhode Islanders with high-quality, affordable care. The company fosters a culture of belonging with transparent, accountable, and collaborative teams, valuing diverse perspectives.
Troubleshoot complex issues related to the Patient Access Curator platform and payer configurations.
Manage a large caseload of escalated support cases via Salesforce, email, and phone.
Collaborate with internal teams, payers, and clients to resolve issues and oversee small projects.
Experian is a global data and technology company that powers opportunities for people and businesses worldwide, using data, analytics, and software across markets like financial services and healthcare. With 23,300 employees across 32 countries and a people-first culture, they are a FTSE 100 company recognized as a top workplace.
Review and analyze insurance denials using EOBs, payer correspondence, and claims data to determine appropriate resolution strategies.
Differentiate between clinical and technical denials and identify required next steps for appeals or reprocessing.
Prepare and submit appeals using supporting documentation such as medical records, appeal letters, and clinical justification when necessary.
Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. They use automated technology to review applications and share top-fitting candidates directly with employers, ensuring a fair and efficient hiring process.
Investigate and resolve complex Navigator system and Disability Tax issues with accuracy and timeliness.
Perform operational tasks such as handling stores, GWIZ requests, orphaned payments, and duplicate tax slips.
Manage security access, user profiles, and system permissions for Disability and Group Life operations.
Manulife Financial Corporation is a leading international financial services provider, helping people make their decisions easier and lives better. It is a large global company with a diverse workforce and an inclusive culture.