Review appeals of adverse benefit determinations within federal and state regulatory timeframes.
Apply medical policy, coding guidelines, and contractual requirements to assess coverage decisions.
Collaborate with medical divisions and respond to state insurance department inquiries regarding benefit complaints.
Arkansas Blue Cross and Blue Shield is a health insurance provider serving Arkansas. It is consistently ranked as one of the best places to work in Central Arkansas, with an inclusive culture and an average employee tenure of 10 years.
Interpret federal and state regulations to ensure compliance and drive process improvements.
Analyze data in Excel to identify trends, savings, and process improvements.
SIHO Insurance Services provides health insurance administration and related services, focusing on payment integrity and regulatory compliance. The company operates in a managed care environment and emphasizes collaboration, professionalism, and adaptability among its employees.
Lead external customer audits and utilization management oversight activities as a subject matter expert.
Analyze complex UM data, investigate findings, and prepare evidence-based responses for regulators and accreditation organizations.
Collaborate with operational, technical, and client-facing teams to drive compliance and process improvements.
This company is a healthcare organization specializing in utilization management and regulatory compliance. It operates with a remote team across the United States, fostering a collaborative and improvement-driven culture.
Provides administrative support to clinical teams including building medical management records and managing authorizations.
Conducts fax and telephonic outreach to members and providers for status updates and engagement.
Supports compliance monitoring and documentation in the medical management system.
Capital Blue Cross is a health insurance provider dedicated to improving the health and well-being of its members and communities. They are recognized as one of the "Best Places to Work in PA" with a culture focused on support, flexibility, and community involvement.
Lead neutral legal support for CMS Office of Hearings, focusing on Medicare RADV appeals.
Research complex issues and draft defensible recommendations for the CMS Hearing Officer.
Provide final quality review, guide staff, and coordinate with CMS leadership.
Empower AI provides AI solutions to federal agencies in Health, Defense, and Civilian missions. With three decades of experience, it fosters transformation and is a 2024 Military Friendly Employer.
Analyze high-value and complex claims, ensuring alignment with carrier guidelines and regulatory requirements.
Oversee delegated claims operations and third-party administrators, monitoring compliance and quality.
Provide subject matter expertise and process improvements to strengthen claims governance and outcomes.
They are an insurance organization focused on claims governance, compliance, and operational performance. They are a growing company that prioritizes accountability, service quality, and effective risk management.
Prepare and submit state-level reimbursement disputes through state portals, agencies, and arbitration entities.
Track deadlines, fees, and payments while keeping accurate case records from filing through resolution.
Monitor state requirements, flag rule changes, and collaborate with analytics teams to keep case data clean.
Pivotal Health is the leading technology platform that helps healthcare providers get paid fairly in a complex reimbursement landscape. We are a collaborative, low-ego team building AI-driven solutions to simplify reimbursement workflows.
You'll be the first intake for payor eligibility inquiries, handle CS tickets and calls, and pull claims data to root-cause issues.
You'll run the ineligible claims review, determine which flags are truly ineligible or product defaults to correct, and communicate outcomes.
You'll fix problems at the source by documenting recurring patterns, building CS-facing materials, and owning eligibility-risk dashboards.
Pivotal Health is a technology platform that helps healthcare providers get paid fairly in a complex reimbursement landscape by simplifying IDR workflows with AI-driven software, data, and service. The team is collaborative and low-ego, building solutions for reimbursement clarity, with a mission to make healthcare reimbursement fairer for providers.
Lead advanced compliance activities for healthcare administrative products including HSAs, FSAs, HRAs, and COBRA.
Apply expert regulatory judgment to risk assessments, compliance monitoring, investigations, and corrective actions.
Collaborate with stakeholders to integrate compliance requirements into strategic initiatives and leverage AI-powered tools.
HealthEquity empowers healthcare consumers by providing administrative solutions like HSAs, HRAs, FSAs, and COBRA. The company is a large, mission-driven organization that values inclusion and connects health and wealth for American families.
Monitor and manage post payment queues, conducting outreach and negotiation calls to providers.
Communicate with providers to verify understanding of NSA claims payments and regulations.
Maintain HIPAA compliance and document all conversations, payment rates, and counter offers.
Reliant Health Partners is an innovative medical claims repricing service provider that helps employers achieve maximum health plan savings. The company tailors services to each client’s needs and values a diverse, inclusive workplace.
Complete coverage analysis tasks to support efficient clinical trial start-up for site clients.
Read and analyze clinical trial protocols and develop activity grids to identify required tests and assessments.
Interpret Medicare policies and billing guidelines to make determinations for clinical trial coverage.
WCG delivers transformational solutions that accelerate clinical research and advance human health. They invest in their people and foster a culture of growth and empowerment.