Perform automated and complex reviews of Medicare Fee-for-Service claims to assess payment accuracy and compliance with CMS guidelines. Document findings, participate in dispute resolution, and support quality assurance through audits and training.
The Dispute Resolution Analyst coordinates the delivery of dispute resolution documents and builds case files based on evidence submitted. They also analyze cases for validity, input data into required systems, and respond to inquiries from appellants, patients, and providers.
The HR Generalist administers key human resources functions including onboarding, employee relations, and benefits administration. They also maintain HRIS data, ensure regulatory compliance, and support leadership with HR operations.
The Clinical Pharmacist Reviewer performs independent clinical and policy reviews of Medicare Part D reconsideration appeals to determine coverage eligibility. They also analyze pharmacy claims and clinical documentation to ensure compliance with CMS regulations and contractual requirements.
The Legal Review Specialist is responsible for reviewing appeal determinations and case files for legal and regulatory sufficiency. They also provide guidance on complex Medicare policy matters and support administrative hearings and government inquiries.
The Medical Reviewer performs automated and complex reviews of Medicare Fee-for-Service claims to assess payment accuracy and compliance with CMS guidelines. They also document findings, participate in dispute resolution, and support quality assurance through audits and training.
The Data Analyst III will utilize advanced analytical tools to identify trends, variances, and actionable insights within healthcare claims and records. They will also collaborate with stakeholders to create visualizations and implement predictive models to support strategic decision-making.
The Data Analyst will utilize various tools to manipulate and analyze healthcare data to identify trends and actionable insights for quality improvement. They will also collaborate with stakeholders to create visual presentations and maintain accurate data documentation.
The Data Analyst will utilize statistical tools to analyze healthcare data, identify trends, and provide actionable insights for quality improvement. They will also collaborate on reporting, mentor junior staff, and design re-measurement strategies to assess the efficacy of healthcare interventions.
The Nurse SME will serve as a senior clinical resource to support program integrity initiatives, audits, and investigations related to fraud, waste, and abuse. They will collaborate with stakeholders to evaluate healthcare data, review medical records, and develop recommendations to improve operational effectiveness and compliance.
The Pharmacist III reviews medical claims and pharmacy cases to identify potential fraud, waste, and abuse through desk reviews and field audits. They also provide clinical expertise as a subject matter expert and support investigative processes through case summaries and legal testimony.
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.
The Program Manager will lead the DHA HPIS program, overseeing daily operations, resource management, and a team of Pharmacy SMEs and Data Analysts. They are responsible for ensuring 99% on-time deliverable compliance, managing risk, and maintaining effective communication with the Defense Health Agency.
Review Medicare Fee-for-Service claims to assess payment accuracy and ensure compliance with CMS policies. Document findings, participate in dispute resolution, and support quality assurance through audits and training.
The Medical Reviewer performs automated and complex reviews of Medicare Fee-for-Service claims to ensure payment accuracy and compliance with CMS rules. They also document findings, participate in dispute resolution, and support quality assurance through audits and training.
