Lead analysis and configuration of complex medical policy content and system edits within claims processing systems to ensure compliance and accurate claims adjudication.
Serve as a coding subject matter expert, translating policy language into actionable criteria, resolving coding-related issues, and mentoring Coding Specialists and operational partners.
Maintain system infrastructure and coding integrity, conduct impact analyses, and participate in cross-functional initiatives to manage medical benefit expense and support organizational goals.
Wellmark is a mutual insurance company owned by its policyholders across Iowa and South Dakota, focused on member well-being and best-in-class service rather than profits. It is a substantial organization with over 80 years of history, fostering a culture of sustainability, innovation, and collegiality.
Champion Sana's payer-side clinical strategy to ensure coverage policies and utilization decisions translate into seamless, high-quality care.
Build and lead a clinician-led payer team responsible for complex case management, utilization management, and high-cost claimant review.
Drive strategy for cost containment initiatives and set evidence-based coverage guidelines aligned with high-value outcomes.
Sana is a health plan solution built for small and midsize businesses, designed around an integrated primary care service. The company is a fully distributed remote-first team across the U.S., valuing curiosity, ownership, and speed.
Serve as a highly specialized expert in AI, providing strategic advice and leadership for high-priority initiatives in areas like revenue models and hospital operations.
Partner with C-suite executives and external stakeholders to develop sustainable practices and build strong relationships to deliver optimal organizational outcomes.
Provide executive-level leadership for organization-wide initiatives, oversee hiring, manage OKRs, mentor staff, and coordinate external resources to drive project execution.
Cleveland Clinic is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. The organization has over 70,800 employees worldwide and is a large, respected health system with locations in multiple U.S. states and countries.
Ensure the timely and accurate payment or denial of claims while meeting regulations, agreements, and policies.
Audit complex Medicare and Medi-Cal claims to impact financial integrity, regulatory adherence, and provider trust.
Collaborate with leadership to identify trends, mitigate risk, and drive process improvements across claims operations.
WelbeHealth serves vulnerable seniors through shared intention, pioneering spirit, and courage to love. They are a participant-focused organization with a commitment to diversity, equity, and inclusion, operating as an equal opportunity employer.
Abstracts and codes physician professional services and diagnosis codes (inpatient, outpatient, diagnostic) using CPT and ICD9 coding.
Trains physicians and staff on documentation, billing, and coding, and provides feedback to ensure compliance and accuracy.
Resolves pre-accounts receivable edits, monitors billing opportunities, and works with Revenue Cycle staff to correct codes and coordinate appeals.
Northwestern Medicine is a leader in the healthcare industry, distinguished by a patient-first approach that cultivates a positive workplace. The organization provides competitive benefits including tuition reimbursement, loan forgiveness, and 401(k) matching, and takes care of its employees across its system.
Partner with physician offices to translate healthcare documentation into standardized codes, ensuring accurate billing and regulatory compliance.
Conduct audits and issue queries to clarify ambiguous documentation, and provide ongoing education to clinical staff on best practices.
Analyze complex medical records, stay updated on coding guidelines, and collaborate with departments like compliance and revenue cycle to optimize processes.
Evergreen Nephrology partners with nephrologists to deliver value-based, person-centered kidney care aimed at improving patient outcomes and quality of life. The company fosters a collaborative culture focused on innovation and holistic patient support, with a team dedicated to transforming the healthcare delivery model.
Facilitate detailed design sessions with clients and stakeholders to successfully design and implement patient reimbursement support programs.
Gather operational and IT requirements, build design documentation, and coordinate the distribution of implementation deliverables to internal and external stakeholders.
Serve as a Subject Matter Expert in Market Access, managing program design from scoping to final sign-off and integrating lessons learned into best practices.
Valeris is a fully integrated life sciences commercialization partner that provides comprehensive solutions spanning the entire healthcare value chain. The company is a merger of PharmaCord and Valeris, serving over 500 life sciences customers and providing access support to millions of patients, with a culture that supports well-being, diversity, and personal growth.
Provide oversight and manage patient care delivery across designated hospice markets to ensure high-quality care.
Triage phone inquiries and medical concerns, facilitate Interdisciplinary Group meetings, and ensure accurate care planning and documentation.
Coach, evaluate, and support team members to ensure compliance with regulatory requirements and clinical best practices.
Gentiva is a national leader providing hospice care, palliative care, home health care, and advanced illness management through nearly 600 locations across 38 states. The company is a family of trusted brands that fosters a collaborative and rewarding career environment where kindness and achievements are celebrated.
Review the statutory framework governing Employer Group Waiver Plans (EGWPs) to identify constraints and flexibilities for model implementation.
Provide expertise on EGWP payment structure and advise on policy options supporting model design and implementation.
Conduct policy research, environmental scanning, and analysis to inform model design decisions and advise on regulatory drafting.
The CMS Innovation Center (CMMI) designs, tests, and expands innovative payment and service delivery models in healthcare to reduce costs while preserving quality of care. It is a U.S. government center operating under Section 1115A of the Social Security Act.
Conducts benefits investigations to determine insurance coverage for enteral nutrition products and services for new and existing patients.
Ensures all required patient documentation is accurately completed, legible, and filed in compliance with Enteral Nutrition Requirements.
Coordinates the timely dispensing of enteral formulas and supplies, manages inventory, and monitors active insurance authorizations and physician orders.
Amerita, an affiliate of BrightSpring Health Services, is a specialty infusion company that provides complex pharmaceutical products and clinical services to patients outside of the hospital. It combines the efficiencies of a large organization with the flexible, responsive, and entrepreneurial spirit of a local provider to deliver excellent service.