The specialist will monitor and audit delegated claims entities to ensure compliance with regulatory and contractual standards. They will also analyze performance metrics, manage corrective action plans, and prepare reports for health plan partners and leadership.
The Case Manager assesses, plans, and implements patient-focused action plans while acting as an advocate through the care continuum. They coordinate services such as specialist visits, durable medical equipment, and home health while maintaining effective communication with healthcare providers and health plans.
The Claims Examiner is responsible for reviewing, analyzing, and processing medical claims while ensuring compliance with plan benefits and healthcare regulations. They must also coordinate with providers and members to resolve inquiries and maintain accurate documentation in management systems.
The Inpatient UM Nurse Case Manager conducts comprehensive patient assessments and collaborates with healthcare providers to develop and implement effective care plans. They also monitor patient progress, facilitate communication between families and care teams, and ensure compliance with regulatory standards.
The Health Plan Contracting Manager will lead the negotiation and management of contracts with health plans, IPAs, and managed care organizations. They are responsible for analyzing reimbursement rates, ensuring contract compliance, and collaborating with internal teams to optimize financial and operational performance.
The Claims Auditor is responsible for auditing medical claims for accuracy, completeness, and compliance with payer guidelines and contractual agreements. They will also analyze claims data to identify billing errors and collaborate with teams to resolve discrepancies and improve processes.
The Staff Accountant will prepare financial statements, manage general ledger reconciliations, and assist with month-end and year-end closing processes. They will also support budgeting, forecasting, and ensure compliance with healthcare accounting standards.
The Staff Accountant is responsible for maintaining accurate financial records, processing accounts payable and receivable, and performing bank and balance sheet reconciliations. They also support month-end and year-end close processes while ensuring compliance with GAAP standards.
The Case Management Coordinator will coordinate patient care plans, monitor progress, and facilitate communication between patients and healthcare providers. They are also responsible for maintaining accurate patient records and assisting with discharge planning and follow-up care.
The analyst will audit and validate provider directory data to ensure accuracy and regulatory compliance. They will also collaborate with internal teams to resolve data discrepancies and generate quality metrics reports.
Design, develop, and maintain reports and dashboards while writing complex SQL queries to extract data from relational databases. Collaborate with stakeholders to gather requirements and ensure data accuracy through validation and quality assurance.
The Rates Configuration Specialist is responsible for configuring, maintaining, and updating rate tables and fee schedules within healthcare management systems. They also audit rate configurations for accuracy and collaborate with various departments to implement changes and resolve discrepancies.
The role involves entering and maintaining accurate provider credentialing data and verifying applications, licenses, and certifications. The clerk will also audit provider records and coordinate with specialists to ensure regulatory compliance.
Manage the end-to-end credentialing and re-credentialing process for healthcare providers, including primary source verification of licenses and certifications. Coordinate with medical staff and health plan partners to ensure timely approvals and ongoing compliance.
Manage end-to-end credentialing and re-credentialing processes for healthcare delivery organization providers. Verify credentials and licenses in compliance with NCQA and regulatory standards while maintaining accurate provider records.
Manage and oversee regulatory cases from initiation to resolution while ensuring compliance with state and federal guidelines. Coordinate with internal and external stakeholders to process submissions, appeals, and grievances.
Provide first-level technical support for web portal users and monitor system performance to ensure optimal functionality. Collaborate with cross-functional teams to enhance portal features and document support processes in a knowledge base.
Review and analyze hospital claims for accuracy and compliance while resolving discrepancies with healthcare providers. Maintain detailed records and assist in developing claims processing guidelines to maximize reimbursement.
The role involves accurately entering and maintaining patient data within electronic health record systems while ensuring HIPAA compliance. Additionally, the clerk supports clinical staff by preparing data summaries and responding to administrative inquiries.
The role involves conducting utilization reviews for outpatient services and collaborating with healthcare providers to assess patient treatment plans. Additionally, the clinician manages insurance authorizations, appeals, and participates in quality improvement initiatives.
The role involves engaging with members through various channels to promote services, gather feedback, and assist with healthcare plan inquiries. The representative will also track engagement metrics and participate in community events to foster relationships.
