Utilizing healthcare experience to perform audit recovery procedures.
Identifying and validating incorrect claim payments.
Researching reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings.
Cotiviti Healthcare is the payment accuracy expert, working with healthcare organizations to recover money, improve processes, strengthen relationships, and maximize their value. They are a well-established company with competitive pay, opportunities to develop professionally, and excellent benefits.
Source, interpret, and scope new payment integrity policies.
Prioritize policy updates based on savings potential and client impact.
Quantify and communicate policy value through data-driven analysis.
Rialtic, Inc. focuses on healthcare payment expertise, client strategy, and product innovation. They seem to have a culture that values collaboration and impact, although the job post doesn't specify size/employees.
Developing advanced analyses of health plan and employer data.
Translating data into actionable strategies that support value-based care.
Building repeatable, intuitive reports and dashboards.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Perform detailed analysis of remittances, explanations of benefits (EOBs),payer correspondence, and account detail to identify underpayments or incorrect claim adjudications.
Prepare and submit detailed appeals with appropriate documentation and contract references to secure accurate reimbursement.
Identify and document systemic payer issues and trends affecting reimbursement.
TREND Health Partners is a tech-enabled payment integrity company. They facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving access to healthcare. Joining TREND Health Partners means becoming part of a dynamic, growing organization that promotes a collaborative and innovative work environment.
Collect, analyze, and interpret clinical, operational, and financial data to assess payer performance and trends.
Maintain SOPs, payer playbooks, internal how-to guides, and reference materials.
Translate front-line payer knowledge into scalable process improvements.
Spring Health is on a mission to revolutionize mental healthcare by removing every barrier that prevents people from getting the help they need, when they need it. They partner with over 450 companies and provide care for 10 million people.
Analyze claims data and develop cost-of-care projections for existing customer renewals and new business opportunities.
Responsible for cost pricing, including evaluating data, building underwriting, and evaluating profitability.
Manage team of pricing and reporting analysts.
Magellan Health, Inc. is committed to making a difference in the health care industry and in the communities where they work and live. They value professional growth and development, total health and wellness, rewards and recognition as well as employee unity.
Collect, clean, process, and analyze potential and current clients’ pharmaceutical data using SQL, R, Python, and MS Excel.
Thoroughly understand internal and external data fields, identify patterns of data irregularities, and improve data quality and intake.
Assist in the writing and maintenance of the Underwriting infrastructure code in SQL, R, and Python.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. The company aims to rebuild trust in healthcare in the U.S. and deploy the infrastructure we need for the care we deserve; they have a startup energy with a focus on delivery.
Supervision and management of a team of Claim Analysts.
Achievement of team quality, production and service expectations.
Answering complex claim or customer service questions.
Luminare Health empowers employees with curated development plans that foster growth and promote rewarding, fulfilling careers. The company helps clients and brokers design custom self-funded Luminare Health plans that manage costs—without compromising benefits—by offering innovative solutions, flexibility, complete data transparency, and member-centered support.
Establishes action plan based on case facts, best practices, protocols, regulatory issues and available resources.
Plans and conduct investigations of claims to confirm coverage and eligibility to medically manage the claims through resolution.
Liberty Mutual strives in a hybrid setting that fosters in-person collaboration and growth. They have comprehensive benefits, workplace flexibility, and professional development opportunities, along with employee resource groups.
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.
Develop comprehensive reports and analyze data to meet client and management needs.
Serve as a technical resource, providing insights and guidance on data analysis.
Help shape decision-making processes and ensure effective data utilization.
Jobgether uses an AI-powered matching process to ensure applications are reviewed quickly, objectively, and fairly against core requirements. They identify the top-fitting candidates and share the shortlist directly with the hiring company, where the internal team manages the final decision and next steps.
Provide high-level customer service to patients and fellow employees.
Review and update billing, codes, and account information.
Ensure accurate billing for all services provided, adhering to compliance.
Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products. With 160 years of clinical excellence, Hanger's vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value.
Jobgether is a platform that connects job seekers with employers. They utilize AI-powered matching to ensure applications are reviewed quickly and fairly.
Conduct audits of payer processed claims to verify accurate reimbursement.
Conduct post-implementation Care Center audits following the audit policy.
Assist the Manager, RI, in leading initiatives that drive efficiency.
Privia Health is a technology-driven physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices. Their platform consists of scalable operations and cloud-based technology to reduce healthcare costs and improve patient outcomes.
Analyze workers compensation claims to determine benefits due.
Ensure ongoing adjudication of claims within service expectations and best practices.
Negotiate settlement of claims within designated authority.
Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape.
Oversee teams of Claims Analysts and ensure high standards of quality and service are met.
Guide team members through complex claims processing and customer service inquiries.
Foster team development and drive improvements within the department.
Jobgether uses an AI-powered matching process to ensure applications are reviewed quickly, objectively, and fairly against the role's core requirements. The system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company.
Develop comprehensive, complex, and accurate information reports.
Create complex data reports for forecasting and benchmarking used by senior management.
Communicate data findings directly to senior management.
Jobgether is a platform that uses an AI-powered matching process to ensure applications are reviewed quickly, objectively, and fairly against a role's core requirements. They identify the top-fitting candidates and share this shortlist with the hiring company.
Investigate, evaluate, and resolve complex and litigated WC claims with accuracy and timeliness.
Set and manage reserves; develop resolution strategies; negotiate settlements.
Partner with defense counsel and vendors; manage litigation plans and outcomes.
Liberty Mutual strives to create a workplace where everyone feels valued and supported. They foster an inclusive culture with comprehensive benefits, workplace flexibility, and professional development opportunities, empowering employees to make a meaningful impact.
Support current Claim Source Review internal process, recommend and develop changes to improve systems efficiency, automation, and effectiveness
Document and communicate complex solutions to internal and external clients promptly
Assess project complexity and estimate development and implementation timeframe
Experian is a global data and technology company, powering opportunities for people and businesses around the world. A FTSE 100 Index company listed on the London Stock Exchange (EXPN), they have a team of 23,300 people across 32 countries and corporate headquarters are in Dublin, Ireland.