Own the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
Design and oversee a robust audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation.
Clover Health aims to improve the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They are a mission-driven team of individuals, who are passionate about solving healthcare's most complicated problems, and strive to put members first.
Develop and maintain standard operating procedures and conduct training for revenue cycle teams to uphold best practices.
Perform audits on payer payments and fee schedules to ensure accurate reimbursement and identify denial trends affecting revenue.
Manage multiple priorities including special projects, Salesforce cases, and process documentation to support key performance goals.
Privia Health is a national physician enablement company that uses technology and scalable operations to help medical groups deliver high-value care in-person and virtually. The company, led by top talent and physician leaders, has a cloud-based platform focused on improving patient outcomes and provider well-being.
Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.
Proactively identify overpayments to ensure accurate claims payments on inpatient services.
Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.
Clover Health is reinventing health insurance by combining the power of data with human empathy to keep its members healthier. They have created custom software and analytics to empower their clinical staff to intervene and provide personalized care to the people who need it most.
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 the resolution of complex financial and benefits billing escalations to ensure accurate member financial tracking.
Perform root-cause analysis on multi-system issues, coordinate corrective actions, and reconcile claims data across platforms.
Act as the primary bridge between internal and external teams to clarify issues and expedite resolutions while communicating clearly with members.
Maven Clinic is the world's largest virtual clinic for women and families, providing clinical, emotional, and financial support through its digital platform across fertility, maternity, parenting, and menopause care. It is an award-winning, mission-driven company trusted by over 2,000 employers and health plans, with a culture recognized for innovation and as a great place to work.
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.
Perform inpatient coding audits and review services remotely.
Identify trends and suggest corrective action plans.
Provide in-service education to clients on coding trends.
UASI has over 40 years of experience and enduring partnerships with its valued clients. The company was recognized as a Top Workplace by the Cincinnati Enquirer in 2022, 2023 and 2024, with a dedicated team and long-term success.
Submit clean, timely claims with accurate CPT, HCPCS, ICD-10 codes, and modifiers.
Review provider documentation and assign accurate codes per ICD-10-CM, CPT, and HEDIS/quality reporting guidelines.
Maintain and contribute to the internal billing rules matrix (payer, state, provider type, modifiers).
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group that reimagines care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care. They enhance existing care teams with compassion, creativity, and an unwavering commitment to children with medical complexity.
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.
Resolve aged claims and appeals via payer portals & outbound phone calls.
Identify non-payment trends and escalate groups of claims to the Dispute Resolution teams.
Propose solutions and collaborate cross-functionally with the Denials Management Steering Committee.
CareDx, Inc. is a precision medicine solutions company focused on healthcare solutions for transplant patients. They offer products, testing services, and digital healthcare solutions. They are the leading provider of genomics-based information for transplant patients.
Accurately process patient payments and maintain payment plans.
Interpret claim notes and update insurance information.
Educate patients on billing concepts and resolve issues.
They support patients with payment processing, billing education, insurance verification, and claims-related inquiries. They are hiring empathetic, accurate, and compliant service providers while navigating healthcare billing systems and policies.
Improve key performance metrics for the focused area within the revenue cycle.
Conduct audits of all revenue cycle processes, vendors, and technology.
Determine root cause of issue and appropriateness of actions taken, assist in corrective action plan development.
ATI Physical Therapy partners with business leaders to improve healthcare. They focus on positive change throughout the revenue cycle and offer competitive benefits.
Conduct audits of medical coding to ensure compliance with standards.
Develop and deliver education to improve documentation quality and coding accuracy.
Assist with internal and external audit preparation and response.
Sprinter Health reimagines how people access care by bringing it directly into their homes. They have supported more than 2 million patients across 22 states, completed over 130,000 in-home visits, and maintained a 92 NPS.