clinical appeals specialist

Ensemble Health Partners

<div><p><b>Thank you for considering a career at Ensemble!</b></p><p></p><p>
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.</p><p></p><p>
Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!</p><p></p><p>
O.N.E Purpose:</p><ul><li><p><b>
Customer Obsession:</b> Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.</p></li><li><p><b>
Embracing New Ideas:</b> Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.</p></li><li><p><b>
Striving for Excellence:</b> Execute at a high level by demonstrating our &ldquo;Best in KLAS&rdquo; Ensemble Difference Principles and consistently delivering outstanding results.</p></li></ul><p></p><p><b>
The Opportunity:
</b></p><p></p><p><b>CAREER OPPORTUNITY OFFERING:</b></p><ul><li><p>
Bonus Incentives</p></li><li><p>
Paid Certifications</p></li><li><p>
Tuition Reimbursement</p></li><li><p>
Comprehensive Benefits</p></li><li><p>
Career Advancement</p></li><li><p>
This position pays between $29.70 - $31.80 based on experience</p></li></ul><p></p><p>
The Acute Coding Appeals Specialist integrates medical coding principles and objectivity in the performance of coding appeals activities. Draws on ICD10CM, ICD10PCS, HCPCS, NCCI, CMS and CMG coding expertise and industry knowledge to substantiate coding principles to determine potential billing/coding issues, and quality concerns. Under indirect supervision, the Coding Appeals Specialist is responsible for reviewing and writing appeals for inpatient Diagnosis Related Group, (DRG) denials in order to support the assigned DRG and to address the clinical documentation utilized in the decision-making process to support the validity of the assigned codes.</p><p></p><p><b>
Job Responsibilities:</b></p><ul><li><p>
The appeals professional integrates medical coding principles and objectivity in the performance of coding appeals/denials activities. Draws on ICD10CM, ICD10PCS, HCPCS, NCCI, CMS and CMG coding expertise and industry knowledge to substantiate coding principles to determine potential billing/coding issues, and quality concerns</p></li><li><p>
Participates in client system education to gain the knowledge necessary to appeal client accounts in ensuring that the coding is supported by the patient's clinical documentation, coding/cdi guidelines and other regulatory standards/guidelines as appropriate</p></li><li><p>
Maintain meticulous documentation, spreadsheets, account, and claim examples of root cause issues. Performs searches of governmental, payor-specific, hospital-specific, regulatory body, and literature rules, regulations, guidelines to identify and coding and billing requirements to make recommendations to client</p></li><li><p>
Assist in education and training for client coding companion as it relates to the outcomes of the coding appeals</p></li><li><p>
Meet established productivity standards for coding appeals &amp; coding certification requirement</p></li><li><p>
Attends in-house sessions to receive updated coding information and changes in coding and/or regulations</p></li><li><p>
Provides excellent customer service, in an organized and efficient manner, while maintaining a positive attitude</p></li></ul><p></p><p><b>
Required Experience:
</b></p><p></p><ul><li><p>Previous inpatient facility coding experience, working appeals, denials and edits</p></li><li><p>
5 years previous experience in coding, required</p></li><li><p>
Advanced knowledge of medical coding and billing systems, documentation, and regulatory requirements</p></li><li><p>
Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.</p></li><li><p>
This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.</p></li></ul><p></p><p><b>
Minimum Education:</b></p><p></p><ul><li><p>
High School Diploma or GED</p></li></ul><p></p><p><b>
Required Certification:</b></p><p></p><ul><li><p>
Active Coding Certification (i.e. RHIA, RHIT, CCS, CIC, CPC, COC, etc.)</p></li></ul><p><br>
#LI-HB1</p><p>
#LI-REMOTE</p><p></p><p><b>
Join an award-winning company</b></p><p></p><p>
Five-time winner of &ldquo;Best in KLAS&rdquo; 2020-2022, 2024-2025</p><p>
Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024</p><p>
22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024</p><p>
Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024</p><p>
Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023</p><p>
Energage Top Workplaces USA 2022-2024</p><p>
Fortune Media Best Workplaces in Healthcare 2024</p><p>
Monster Top Workplace for Remote Work 2024</p><p>
Great Place to Work certified 2023-2024</p><ul><li><p>
Innovation</p></li><li><p>
Work-Life Flexibility</p></li><li><p>
Leadership</p></li><li><p>
Purpose + Values</p></li></ul><p></p><p>
Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:</p><ul><li><p><b>
Associate Benefits &ndash; </b>We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.</p></li><li><p><b>
Our Culture</b> &ndash; Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
</p></li><li><p><b>Growth &ndash; </b>We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.</p></li><li><p><b>
Recognition &ndash; </b>We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.</p></li></ul><p></p><p>
Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.</p><p></p><p>
Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com.</p><p></p><p>
This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role&rsquo;s range.</p><p></p><p>
Employment Disclaimers &ndash; Ensemble</p></div>

Acute Coding Appeals Specialist

Pantherx Specialty Llc

<p></p><div><p><b>7,000 Diseases - 500 Treatments - 1 Rare Pharmacy</b></p><p><i>
PANTHERx is the nation&rsquo;s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.</i></p><p><i>
If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don&rsquo;t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.
</i></p><p><i>We are seeking team members who:</i></p><p><i>
Are inspired and compassionate problem solvers;</i></p><p><i>
Produce high quality work;</i></p><p><i>
Thrive in the excitement of the ever-challenging environment of modern medicine; and</i></p><p><i>
Are committed to achieving superior health outcomes for people living with rare and devastating diseases.</i></p><p><i>
At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.</i></p><p><b>
Join the PANTHERx team, and define your own RxARE future in healthcare!</b></p><p><b>
Location:</b> Pittsburgh, PA; Hybrid</p><p><b><br>
Classification:</b> Non-Exempt</p><p><b>
Status:</b> Full Time</p><p><b>
Reports to:</b> Manager, Clinical Programs</p><p><b>
Purpose:</b></p><p>
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.</p><p><b>
Responsibilities:</b></p><ul><li>
Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.</li><li>
Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.</li><li>
Creates initiatives to increase patient adherence and optimize patient care.</li><li>
Possess a broad and deep understanding of assigned disease states, products, and clinical programs.</li><li>
Closes collaboration with program team members as well as external stakeholders.</li><li>
Performs appropriate and accurate documentation of cases using call management software.</li><li>
Demonstrates appropriate judgment skills to be able to make independent clinical decisions.</li><li>
Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization. Embraces diversity and demonstrates the ability to work together.</li><li>
Provides superior customer service to internal and external clients, customers, and patients.</li><li>
Assumes accountability for own professional practice in achieving patient outcomes.</li><li>
Completes all other duties as assigned.</li></ul><p><b>
Required Qualifications:</b></p><ul><li>
Associate degree or bachelor&rsquo;s degree from an accredited nursing school as a Registered Nurse (RN).</li><li>
Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.</li><li>
Strong writing and grammar skills.</li><li>
Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.</li><li>
Demonstrated ability to work independently and meet goals.</li></ul><p><b>
Preferred Qualifications:</b></p><ul><li>
1-3 years of specialty pharmacy experience</li></ul><p><b>
Work Environment:</b></p><p>
PANTHERx Rare Pharmacy offers flexibility only to eligible employees to work hybrid or remotely without compromising work performance, productivity, or team collaboration. This role routinely uses standard office equipment such as computers and phones.</p><p><b>
Physical</b> <b>Demands:</b></p><p>
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.</p><p><b>
Benefits:</b></p><p>
Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!</p><p><b>
Equal Opportunity:</b></p><p>
PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.</p></div><p></p>

Clinical Authorization and Appeals Specialist

Tanaq Health

<div>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 <strong>
  Overview
  <br/>
  <br/>
 </strong>
 Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.
 <br/>
 <br/>
 <strong>
  About The Role
  <br/>
  <br/>
 </strong>
 We are seeking a
 <strong>
  Clinical Appeals Reviewer
 </strong>
 to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
 <br/>
 <br/>
 This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
  </li>
  <li>
   Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
  </li>
  <li>
   Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
  </li>
  <li>
   Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
  </li>
  <li>
   Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
  </li>
  <li>
   Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
  </li>
  <li>
   Participates in case-specific verbal discussions.
  </li>
  <li>
   Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
  </li>
  <li>
   Plans responses to statistical analysis challenges with assistance from statisticians.
  </li>
  <li>
   Attends meetings and participates in workgroups at management's direction.
  </li>
  <li>
   Conducts quality reviews, as needed.
  </li>
  <li>
   Serves as a subject matter expert.
  </li>
  <li>
   Mentors and/or trains staff.
  </li>
  <li>
   May conduct quality reviews and audits.
  </li>
  <li>
   Participates in special projects and performs other duties as assigned.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 <strong>
  Required Skills and Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
  </li>
  <li>
   Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
  </li>
  <li>
   Demonstrated experience writing or making medical necessity decisions.
  </li>
  <li>
   Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
  </li>
  <li>
   Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
  </li>
  <li>
   Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
  </li>
  <li>
   Prioritize and organize work tasks to handle multitasking and meet deadlines.
  </li>
  <li>
   Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
  </li>
  <li>
   Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
  </li>
  <li>
   Experience in making decisions that support business objectives and goals.
  </li>
  <li>
   Ability to identify and resolve problems or refer issues appropriately.
  </li>
  <li>
   Communicate effectively verbally and in writing.
  </li>
  <li>
   Adapt to the needs of internal and external customers.
  </li>
  <li>
   Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
  </li>
  <li>
   Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
  </li>
  <li>
   Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
  </li>
  <li>
   Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
  </li>
  <li>
   Must possess a valid driver's license with a clear and satisfactory driving record.
  </li>
  <li>
   Ability to obtain and maintain public trust clearance and customer approval.
  </li>
  <li>
   Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Education and Training
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Associate's degree or 60 or more credit hours towards a Bachelor&rsquo;s degree from an accredited college or university in healthcare or related discipline.
  </li>
  <li>
   Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for an Associate&rsquo;s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Requirements And Work Environment
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
  </li>
  <li>
   Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
  </li>
  <li>
   May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Who We Are
  <br/>
  <br/>
 </strong>
 Tanaq Management Services (TMS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.
 <br/>
 <br/>
 <strong>
  Our Commitment to Non-Discrimination
  <br/>
  <br/>
 </strong>
 Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
 <br/>
 <br/>
 If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.
 <br/>
 <br/>
 <strong>
  Notice on Candidate AI Usage
  <br/>
  <br/>
 </strong>
 Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at accommodation@tanaq.com.
 <br/>
 <br/>
 <strong>
  To Apply For This Positions, Visit
  <br/>
  <br/>
 </strong>
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>


Clinical Appeals Reviewer (Licensed Healthcare Professional)

Tampa General Hospital

<div><div><b>Pharmacy Billing Specialist - Outpatient Specialty</b> <b>-</b> <b>(</b><b>260001CE</b><b>)</b><div>
</div></div><div><b>
Description</b><div></div><p><br>
The Pharmacy Billing Specialist handles all medication billing functions within Pharmacy Services. Responsibilities include verifying insurance eligibility, facilitating prior authorizations, and collaborating with third-party payers and clinical offices. The specialist works with patients and providers to ensure access to medications and assists with denial appeals and financial assistance through funding sources. Additionally, the role involves auditing hospital pharmacy billing, resolving claim rejections, and supporting medical bill audits. The specialist performs duties in alignment with TGH&rsquo;s mission, vision, and values.</p><div><br>
</div></div><div><b>
Qualifications</b><div>
</div><ul><li>
Associate's Degree Relevant Field</li><li>
Registered Pharmacy Technician</li><li>
Two (2) years of experience in healthcare, retail, pharmacy, or billing. Experience may be considered in<br>
lieu of degree.</li></ul><div>
</div></div><div><b>
Primary Location</b><b>:</b> Tampa</div><div><b>
Work Locations</b><b>:</b> TGH Main Campus 1 Tampa General Circle Tampa 33601</div><div><b>
Eligible for Remote Work</b><b>:</b> Hybrid Remote</div><div><b>
Job</b><b>:</b> Pharmacy</div><div><b>
Organization</b><b>:</b> Florida Health Sciences Center Tampa General Hospital</div><div><b>
Schedule</b><b>:</b> Full-time</div><div><b>
Scheduled Days</b><b>:</b> Monday, Tuesday, Wednesday, Thursday, Friday</div><div><b>
Shift</b><b>:</b> Day Job</div><div><b>
Job Type</b><b>:</b> Hybrid Remote</div><div><b>
Shift Hours</b><b>:</b> Day shifts 8am to 4:30pm Monday to Friday</div><div><b>
Minimum Salary</b><b>:</b> 43,180.80</div><div><b>
Job Posting</b><b>:</b> Mar 31, 2026, 9:15:20 AM</div></div>

Pharmacy Billing Specialist - Outpatient Specialty

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Authorization Technician II
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Clinical
</div></div></div></div><div><div><div><div><b>Department: </b>Utilization Management
</div></div></div></div><div><div><div><div><b>Location:
</b>Los Angeles, CA, US, 90017
</div></div></div></div><div><div><div><div><b>Position Type: </b>Full Time
</div></div></div></div><div><div><div><div><b>Requisition ID: </b>13058
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.)</div><br>
<div></div>
<div>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation&rsquo;s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br>
<br>
Mission: L.A. Care&rsquo;s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br>
</div><div><div><div><div>Job Summary</div>
</div><div><div>
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</div><br>
<div></div>
<div>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</div><br>
<div></div>
<div>In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</div>
</div></div><div><div><div>
Duties</div>
</div><div><div>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</div>
<div></div><div>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</div>
<div></div><div>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</div>
<div></div><div>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</div>
<div>Perform other duties as assigned. (10%)</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>High School Diploma/or High School Equivalency Certificate</div></div></div><div><div><div>
Education Preferred</div>
</div></div><div></div><div><div><div>Experience</div>
</div><div><div><b>
Required:</b></div>
<p>At least 6 months of health care experience.</p><br>
<p></p>
<p>Experience working in a cross functional work environment.</p><br>
<p></p>
<p><b>Preferred:</b></p>
<p>Experience in Medi-Cal managed care.</p><br>
<p></p>
<p>1 year of experience in UM/Prior Authorization.</p>
</div></div><div><div><div>
Skills</div>
</div><div><div><b>
Required:</b></div>
<p>Demonstrated proficiency in Medical Terminology required.</p><br>
<p></p>
<p>Strong verbal and written office communication skills.</p><br>
<p></p>
<p>Proficient with Microsoft Office Suite and Adobe PDF. and</p><br>
<p></p><p>Excellent organizational, interpersonal and time management skills.</p><br>
<p></p><p>Must be detail-oriented and an enthusiastic team player.</p><br>
<div></div>
<div><b>Preferred:</b></div>
<p>Knowledge of QNXT computer systems a plus.</p><br>
<p></p>
<p>Knowledge of the UM patient referral process.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s health plan eligibility.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s benefits coverage.</p><br>
<p></p><p>Knowledge of Health Plan regulations.</p><br>
<p></p>
<p>Knowledge of HMO/UM functions.</p><br>
<p></p>
<p>Knowledge of ICD-10/CPT coding.</p><br>
<p></p><p>Proficient utilizing electronic medical records and documentation programs.</p>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Medical Coding Certification</div></div></div><div><div><div>
Required Training</div>
</div></div><div></div><div><div><div>Physical Requirements</div>
</div><div><div>Light</div></div></div><div><div><div>
Additional Information</div>
</div><div><div><b>
Required:</b></div>
<div>Weekends and holidays hours may be required, as well as OT based on a business need.</div>
</div></div></div><div><b>
Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</div><br>
<div></div>
<div><b>L.A. Care offers a wide range of benefits including</b></div>
<ul><li>Paid Time Off (PTO)</li>
<li>Tuition Reimbursement</li>
<li>Retirement Plans</li>
<li>Medical, Dental and Vision</li>
<li>Wellness Program</li>
<li>Volunteer Time Off (VTO)</li></ul><div><br>
</div></div></div></div></div><p><br>
<b>Nearest Major Market: </b>Los Angeles
<br>
<b>Job Segment: </b>EMR, Claims, Data Entry, Medical Coding, Healthcare, Insurance, Administrative</p></div></div></div><div></div>

Authorization Technician II

StoneGate Senior Living

<p>Insurance Biller<br/></p><p>100% On Site<br/></p><p>StoneGate Senior Living<br/></p><p>Lewisville, TX<br/></p><p>StoneGate Senior Living, a leading provider of Long-Term Care, Skilled Nursing and Rehabilitative Care in Lewisville, TX has an opportunity for an Insurance Biller with Managed Care Insurance experience to join our team! A rewarding career is waiting for you with a company that specializes in long-term and rehabilitative care! If you are an experienced Insurance Biller with Managed Care experience, we have the opportunity for you. This is not a remote position.<br/></p><p>As the Insurance Biller you are responsible for verifying, facilitating insurance authorizations, and billing via UB04s for Skilled Nursing patients. Duties may also include communicating with clinical liaisons, insurance carriers, and Skilled Nursing Facilities. The specialist will verify patients&rsquo; demographics, gathering and recording pertinent information, conform insurance/payor benefits, review preauthorization and complete processes and bill inpatients to the Skilled Nursing Facilities. Follow-up on all claims, moving copays, posting cash, appeals for non-paid claims and work all balances.<br/></p><p>Come be a part of our mission to provide superior clinical care, rehabilitation, wellness, and supportive services that meet the wants, needs, and expectations of our patients and residents. We offer competitive compensation, health, dental, and vision insurance, company paid life insurance, holiday pay, paid time off, employee appreciation events and much more. We look forward to you joining our team!<br/></p><p>Responsibilities:<br/></p><p>Understanding of SNF billing requirements and systems.<br/></p><p>Bills Insurance via UB04 detailed billing, non-episodic<br/></p><p>Tie NOMNCs to Insurance Authorization for billing and appeals.<br/></p><p>Full understand of ISNP systems and ability to bill per guidelines<br/></p><p>Detailed UB04/837 understanding<br/></p><p>Manage large load of claims from multiple facilities within deadlines<br/></p><p>Work closely with Team Members and billing issue resolutions<br/></p><p>Communicates effectively with clinical reimbursement<br/></p><p>Knowledge/understanding of Pharmacy exclusions and related billing procedures<br/></p><p>Post incoming remits and balance books<br/></p><p>Understand basic accounting knowledge and processes<br/></p><p>Working knowledge of national insurance clearing house systems<br/></p><p>Contact patient&rsquo;s insurance to confirm and determine amount of coverage and benefits, deductible due, length of stay and if authorization is required.<br/></p><p>Communicates authorization status electronically and verbally if needed. .<br/></p><p>Maintains open communication with Team Members and Clinical Liaisons to ensure teamwork, cooperation and mutual respect.<br/></p><p><b>**</b><b>This is not a Coder position</b><b>**</b>**<br/></p><p>Requirements:<br/></p><p>High school diploma. College degree in Business preferred<br/></p><p>Basic Accounting/bookkeeping skills needed.<br/></p><p>UB04 experience required<br/></p><p>Must have Managed Care Insurance experience.<br/></p><p>Experience in Skilled Nursing authorizations preferred.<br/></p><p>Strong knowledge and understanding of Medicare, Managed Care, HMO/PPO plans and authorization/referral requirements.<br/></p><p>Ability to understand medical terminology.<br/></p><p>Ability to multi-task and prioritize duties.<br/></p><p>Strong Excel skills<br/></p><p>Excellent organizational skills.<br/></p><p>Uses a computer proficiently.<br/></p><p>Speaks and communicates English effectively, both in verbal and written format.<br/></p><p><b>**</b><b>Note: this is NOT a coder position</b><b>**</b><br/></p>

Insurance Biller

VanderHouwen

<div>
 Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.
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 <em>
  This role is a Hybrid model in Idaho. Applicants must be able to maintain flexibility to occasionally support work outside of standard business hours may be required.
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  Clinical Appeals Nurse (RN) Responsibilities
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 </strong>
 <ul>
  <li>
   Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
  </li>
  <li>
   Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
  </li>
  <li>
   Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
  </li>
  <li>
   Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
  </li>
  <li>
   Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Clinical Appeals Nurse (RN) Qualifications
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 </strong>
 <ul>
  <li>
   Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor&rsquo;s degree in Nursing preferred.
  </li>
  <li>
   Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
  </li>
  <li>
   Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
  </li>
  <li>
   Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
  </li>
  <li>
   Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Compensation: $28-$30/hr. (DOE)
 </strong>
 <strong>
  VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
  <br/>
  <br/>
 </strong>
 As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.
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 <strong>
  Meet VanderHouwen
  <br/>
  <br/>
 </strong>
 What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we're in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies' staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.
 <br/>
 <br/>
 VanderHouwen is an award-winning, Women &amp; Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!
 <br/>
 <br/>
 VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.
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Clinical Appeals Nurse (RN)

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