Review Medicare Fee-for-Service claims, including Part A/B, DMEPOS, and Home Health/Hospice, to assess payment accuracy under Medicare policies and CMS rules. Document findings, support claim disputes and quality assurance, maintain privacy and security compliance, and collaborate on consistent, accurate review processes.
Perform automated and complex reviews of Medicare Fee-for-Service claims to assess payment accuracy according to CMS policies. Document findings, participate in dispute resolution, and support quality assurance through audits and training.
Coordinates dispute and reconsideration documents and decisions, builds case files, and assesses requests for validity and case type under applicable CMS or customer requirements. Enters case data, responds to inquiries, routes requests, flags suspected fraud or abuse, and supports related projects.
The Senior Claims Operations Lead will define and document claims workflows, standard operating procedures, and operational readiness plans for the World Trade Center Health Program. They will also provide technical subject matter expertise, mentor claims processors, and support quality improvement initiatives.
The Junior Healthcare Claims Analyst is responsible for reviewing and processing healthcare claims in accordance with established procedures, benefit requirements, and quality standards. They will also research claim discrepancies, document processing decisions, and escalate complex issues to senior team members.
The Pharmacy SME will provide expert guidance on pharmacy benefit design, acquisition strategies, and modernization efforts within the DoD and TRICARE environments. They act as a bridge between commercial innovation and military healthcare requirements to ensure compliant and mission-focused outcomes.
