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complex claims consultant healthcare

CNA Insurance

<div><p>You have a clear vision of where your career can go. And we have the leadership to help you get there. At CNA, we strive to create a culture in which people know they matter and are part of something important, ensuring the abilities of all employees are used to their fullest potential.</p><p></p>
This individual contributor position works under general direction, and within broad authority limits, to manage commercial claims with high complexity and exposure for a specialized line of business. Responsibilities include the coordination of all claim resolution activities in accordance with company protocols, while achieving quality and customer service standards. Position requires regular communication with customers and insureds and may have regional, industry segment or company-wide scope of responsibility.<p></p><p><b>
JOB DESCRIPTION:</b></p><p></p><p><b>
Essential Duties &amp; Responsibilities</b></p><p><i>
Performs a combination of duties in accordance with departmental guidelines:</i></p><ul><li>
Manages an inventory of highly complex commercial claims, with large exposures that require a high degree of specialized technical expertise and coordination, by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits.
</li><li>Ensures exceptional customer service by managing all aspects of the claim, interacting professionally and effectively, achieving quality and cycle time standards, providing timely updates and responding promptly to inquiries and requests for information.</li><li>
Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters, estimating potential claim valuation, and following company's claim handling protocols.</li><li>
Leads focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim.</li><li>
Resolves claims by collaborating with internal and external business partners to develop, own and execute a claim resolution strategy, that includes management of timely and adequate reserves, collaborating with coverage experts, negotiating complex settlements, partnering with counsel to manage complex litigation and authorizing payments within scope of authority.</li><li>
Establishes and manages claim budgets by achieving timely claim resolution, selecting and actively overseeing appropriate resources, authorizing expense payments and delivering high quality service in an efficient manner.</li><li>
Realizes and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Claim, Recovery or SIU resources for further investigation.</li><li>
Achieves quality standards by appropriately managing each claim to ensure that all company protocols are followed, work is accurate and timely, all files are properly documented and claims are resolved and paid timely.</li><li>
Keeps senior leadership informed of significant risks and losses by completing loss summaries, identifying claims to include on oversight/watch lists, and preparing and presenting succinct summaries to senior management.</li><li>
Maintains subject matter expertise and ensures compliance with state/local regulatory requirements by following company guidelines, and staying current on commercial insurance laws, regulations or trends for line of business.</li><li>
Mentors, guides, develops and delivers training to less experienced Claim Professionals.</li></ul><p></p><p><i>
May perform additional duties as assigned.</i></p><p></p><p><b>
Reporting Relationship</b></p><p>
Typically Director or above<br>
<br>
<b>Skills, Knowledge &amp; Abilities</b></p><ul><li>
Thorough knowledge of the commercial insurance industry, products, policy language, coverage, and claim practices.</li><li>
Strong communication and presentation skills both verbal and written, including the ability to communicate business and technical information clearly.</li><li>
Demonstrated analytical and investigative mindset with critical thinking skills and ability to make sound business decisions, and to effectively evaluate and resolve ambiguous, complex and challenging business problems.
</li><li>Strong work ethic, with demonstrated time management and organizational skills.</li><li>
Ability to work in a fast-paced environment at high levels of productivity.</li><li>
Demonstrated ability to negotiate complex settlements.</li><li>
Experience interpreting complex commercial insurance policies and coverage.</li><li>
Ability to manage multiple and shifting priorities in a fast-paced and challenging environment.</li><li>
Knowledge of Microsoft Office Suite and ability to learn business-related software.</li><li>
Demonstrated ability to value diverse opinions and ideas.</li></ul><p></p><p><b>
Education &amp; Experience</b></p><ul><li>
Bachelor's Degree or equivalent experience Typically a minimum six years of relevant experience, preferably in claim handling Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable Prior negotiation experience Professional designations preferred (e.g. CPCU)</li></ul><p></p><p>
#LI-KC2</p><p>
#LI-Hybrid</p><p></p><p><i>
I</i><i>n certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In </i><i>District of Columbia</i><i>,</i><i> </i><i>California, Colorado, Connecticut, </i><i>Illinois</i>, <i>Maryland</i><i>, </i><i>Massachusetts</i>,<i> New York and Washington,</i> <i>the national base pay range for this job level is</i><i> $72,000 to $141,000 </i><i>annually. Salary</i><i> determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees &ndash; and their family members &ndash; achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA&rsquo;s benefits, please visit </i><i>cnabenefits.com</i><i>.</i></p><p></p><p>
CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact leaveadministration@cna.com.</p></div>

Complex Claims Consultant, Healthcare

UCLA Health

<div><div><b>Description</b><p></p><p><b>
Real Estate | Planning, Design &amp; Construction
</b></p><p>Manage capital design and construction projects that directly support UCLA Health&rsquo;s clinical and operational growth. As a Design &amp; Construction Project Manager, you will lead projects under $10M from concept through completion. You will define scope, manage budgets and schedules, coordinate with stakeholders, and ensure compliance with regulatory and organizational standards.</p><p><b>
In this role, you will:</b></p><ul><li>Manage design and construction capital projects under $10M, including scope, schedule, budget, and execution strategy.</li><li>Lead project planning, design, and consultant coordination to ensure quality, compliance, and timely delivery.</li><li>Oversee regulatory approvals, plan check processes, and adherence to building codes and healthcare standards.</li><li>Develop and manage project budgets, cost estimates, timelines, and key milestones.</li><li>Lead bidding, contract negotiation, and vendor management, including contractor selection and project execution.</li><li>Oversee construction activities, including RFIs, submittals, change orders, and project closeout.</li><li>Coordinate communication across clinical, operational, and leadership stakeholders to minimize disruption.</li><li>Partner with regulatory teams to support licensing, compliance, and audit readiness.</li><li>Ensure complete project closeout, including documentation, record drawings, and turnover requirements.</li></ul><p><b>
Salary Range:</b></p><p>
$95,400 to $208,300 annually. Target salary $100,000 to $135,000 annually.</p></div><div><b><br>
Qualifications</b><p></p><p><b>
Required</b></p><ul><li>Bachelor&rsquo;s degree in architecture, engineering, construction management, or a related field, or equivalent combination of education and experience.</li><li>5 or more years of related experience or training in design, construction, facilities project management, or a closely related field.</li><li>Demonstrated experience managing design and construction projects, including scope, schedule, and budget oversight.</li><li>Knowledge of building codes, regulatory requirements, and healthcare construction standards.</li><li>Ability to manage multiple projects simultaneously in a complex, fast paced environment.</li><li>Strong project management, vendor coordination, and stakeholder communication skills.</li><li>Strong written and verbal communication skills with the ability to work across multidisciplinary teams.</li></ul><p><b>
Preferred</b></p><ul><li>Experience managing healthcare or hospital construction projects.</li><li>Knowledge of HCAI, OSHPD, or similar healthcare regulatory approval processes.</li><li>Experience with space planning, interior design, or furniture and equipment coordination.</li><li>Familiarity with University of California systems, processes, or capital programs.</li><li>Certification in project management such as PMP or equivalent.</li></ul></div></div>

Design & Construction Project Manager

Ultimate Staffing

<div>
 <p>
  We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of
  <strong>
   ICD‑9 and ICD‑10 diagnosis coding
  </strong>
  and healthcare billing standards.
 </p>
 <p>
  <strong>
   Key Responsibilities:
  </strong>
 </p>
 <ul>
  <li>
   Review and process medical claims for completeness, accuracy, and compliance
  </li>
  <li>
   Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
  </li>
  <li>
   Identify coding discrepancies, overpayments, and potential fraud or abuse
  </li>
  <li>
   Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
  </li>
  <li>
   Document determinations and communicate findings as needed
  </li>
 </ul>
 <p>
  <strong>
   Qualifications:
  </strong>
 </p>
 <ul>
  <li>
   Proven experience as a Medical Claims Examiner or similar role
  </li>
  <li>
   Strong knowledge of
   <strong>
    ICD‑9 and ICD‑10 coding
   </strong>
  </li>
  <li>
   Familiarity with CPT, HCPCS, and medical billing guidelines
  </li>
  <li>
   Attention to detail and strong analytical skills
  </li>
  <li>
   Proficiency with claims processing systems and MS Office
  </li>
 </ul>
 <p>
  <strong>
   Preferred:
  </strong>
 </p>
 <ul>
  <li>
   CPC, CCS, or related certification
  </li>
  <li>
   Experience with Medicare, Medicaid, or commercial insurance claims
   <br/>
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <strong>
  Desired Skills and Experience
  <br/>
  <br/>
 </strong>
 We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of ICD‑9 and ICD‑10 diagnosis coding and healthcare billing standards.
 <br/>
 Key Responsibilities:
 <br/>
 <br/>
 Review and process medical claims for completeness, accuracy, and compliance
 <br/>
 Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
 <br/>
 Identify coding discrepancies, overpayments, and potential fraud or abuse
 <br/>
 Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
 <br/>
 Document determinations and communicate findings as needed
 <br/>
 <br/>
 Qualifications:
 <br/>
 <br/>
 Proven experience as a Medical Claims Examiner or similar role
 <br/>
 Strong knowledge of ICD‑9 and ICD‑10 coding
 <br/>
 Familiarity with CPT, HCPCS, and medical billing guidelines
 <br/>
 Attention to detail and strong analytical skills
 <br/>
 Proficiency with claims processing systems and MS Office
 <br/>
 <br/>
 Preferred:
 <br/>
 <br/>
 CPC, CCS, or related certification
 <br/>
 Experience with Medicare, Medicaid, or commercial insurance claims
 <br/>
 <br/>
 <p>
  <em>
   All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.
  </em>
 </p>
</div>


Medical Claims Examiner

The Hanover Insurance Group

For more than 170 years, The Hanover has been committed to delivering on our promises and being there when it matters the most. We live our values every day, demonstrating we CARE through our values, Sustainability initiatives and inclusive corporate culture.
<br><br>
We are excited to announce a key role on our Large Loss Property team: Regional General Adjuster, Specialized Claims. This full time, exempt position offers remote flexibility and the opportunity to contribute to a collaborative, high performing group that manages some of our most significant claims.
<br><br>
This role covers the Northwest Territory. We are considering candidates who live in California, Washington, Oregon, Nevada, Utah, Colorado, or Idaho.
<br><br>
<b>Position Overview:</b> The Regional General Adjuster Specialized Claims is a senior-level claims position responsible for the full lifecycle management of highly complex and high-value commercial property claims. This includes the investigation, evaluation, negotiation, and resolution of claims that represent the company’s largest damage exposures and often involve intricate coverage issues.
<br>Claims handled in this role may originate from anywhere in the country and frequently require on-site field consultation and investigation. The position demands a high level of technical expertise, strategic thinking, and collaboration with internal and external stakeholders, including legal teams, engineers, and other subject matter experts.
<br><br>
<b>Responsibilities/Essential Functions:</b><br>
<ul>
<li>Independently lead investigations and manage the full lifecycle of highly complex, sensitive, and specialized claims.</li>
<li>Analyze coverage, damages, and financial exposure; develop tailored resolution strategies and negotiate high-value or contested claims.</li>
<li>Issue reservation of rights and draft coverage letters, including manuscript and ISO/non-ISO forms; interpret and apply commercial coverages and legal principles.</li>
<li>Set activities, reserves, and authorize payments within high authority limits.</li>
<li>Coordinate with internal and external experts (e.g., forensic analysts, underwriters, legal counsel, contractors) to ensure thorough evaluations and resolution.</li>
<li>Identify and pursue risk transfer opportunities; manage suspicious claims and refer to Special Investigation Unit as needed.</li>
<li>Serve as a subject matter expert (SME) for consistent handling of large losses; provide consultation on claim strategies and co-adjust files to support development.</li>
<li>Ensure compliance across jurisdictions including licensing, forms, deadlines, and accounting; maintain accurate and complete claim records.</li>
<li>Protect personally identifiable information (PII) and promote best practices across the team.</li>
<li>Represent the company in litigation, mediations, settlement conferences, and arbitrations; provide large loss and reinsurance reporting to underwriting.</li>
<li>Lead cross-functional meetings and collaborate with underwriting, agents, vendors, and legal teams to drive consensus and resolve claims.</li>
<li>Identify coverage gaps and partner with product management to enhance offerings.</li>
<li>Mentor and support less experienced adjusters; evaluate training programs and recommend improvements.</li>
<li>Lead quality initiatives to streamline workflows; use data tools to analyze trends and correct inconsistencies.</li>
<li>Maintain strong time and desk management skills; prepare reports and contribute to special projects.</li>
<li>Attend industry events and continuing education seminars to stay current on best practices.</li>
<li>Tailor communication strategies for specialized claims and maintain regular updates with leadership.</li>
<li>Build and maintain strong relationships with customers and stakeholders.</li>
</ul>
<b>Essential Skills and Experience:</b><br>
<ul>
<li>Bachelor’s degree preferred; equivalent experience accepted.</li>
<li>Typically requires 8+ years' experience handling complex large loss property claims</li>
<li>Extensive experience handling highly complex, high-value claims with significant legal, financial, and reputational exposure.</li>
<li>Recognized authority in negotiation and resolution of complex claims; able to shape best practices and influence outcomes.</li>
<li>Demonstrated expertise in analyzing policy coverage, legal liability, and regulatory frameworks across jurisdictions.</li>
<li>Represent the company in trials, mediations, and arbitrations.</li>
<li>Experience mentoring others and contributing to the development of investigative techniques, compliance protocols, and claims handling standards.</li>
<li>Strong written and verbal communication skills; able to simplify complex information and handle sensitive issues with professionalism.</li>
<li>Skilled in selecting appropriate communication channels and demonstrating empathy across diverse stakeholder groups.</li>
<li>Ability to draft clear, factual, and objective work product without opinion.</li>
<li>Highly organized with proven ability to manage complex workflows, projects, and competing priorities.</li>
<li>Demonstrated time management and organizational skills; able to coach others in these areas.</li>
<li>Deep understanding of insurance principles, coverage interpretation, and jurisdictional requirements.</li>
<li>Strategic thinker with sound judgment; able to make informed decisions independently and assess financial implications.</li>
<li>Expert in identifying and mitigating legal, regulatory, and reputational risks</li>
<li>Recognized for developing empathetic customer service strategies and delivering exceptional service.</li>
<li>Proficiency with Xactimate/ Xactanalysis and standard office software, including Microsoft Word and Microsoft Excel.</li>
</ul>
<b>Core Capabilities:</b><br>
<b>Analytical Reasoning:</b> The ability to identify problems, understand your impact, gather input and data, and develop an effective solution.
<br><b>Customer Centricity:</b> Makes customers/clients and their needs a primary focus of one’s actions; shows interest in and understanding of the needs and expectations of internal and external customers; gains customer trust and respect; meets or exceeds customer expectations.
<br><b>Digital Fluency:</b> Effectively uses digital tools and technology appropriately to find, evaluate, create, and communicate information understands how to navigate digital platforms, use software applications, and leverage technology for productivity and communication purposes.
<br><b>Persuasion and Influence:</b> Uses appropriate interpersonal skills and techniques to gain acceptance for ideas or solutions; uses influencing strategies to gain genuine agreements; seeks to persuade rather than force solutions or impose decisions or regulations.
<br><b>Professional Insurance Acumen:</b> Demonstrates a deepening understanding of the insurance industry and the ability to apply specialized technical skills to address complex challenges, adapt to industry trends, and drive value for the organization.
<br><b>Planning and Execution:</b> Plans, prioritizes and manages resources and time effectively to achieve specific goals or deadlines.
<br><br>
<b>Physical Demands and Work Environment:</b><br>
<ul>
<li>Ability to use a personal computer and other standard office equipment.</li>
<li>Ability to sit and/or stand for extended periods.</li>
<li>Required to work on-site as needed.</li>
<li>Ability to travel as necessary.</li>
<li>Ability to work in a fast-paced, changing or stressful environment.</li>
<li>Ability to perform work in a noisy/loud work environment.</li>
<li>May be required to have and maintain sufficient home-based internet connection</li>
<li>Ability to walk, stand, bend, kneel, and climb for extended periods during field inspections.</li>
<li>Ability to safely lift, carry and handle equipment weighing approximately 25-40 lbs.</li>
<li>Ability to work in adverse environmental conditions and within damaged or partially compromised structures.</li>
<li>Ability to access and inspect roofs using appropriate safety measures.</li>
</ul>
<b>CAREER DEVELOPMENT:</b><br>
It’s not just a job, it’s a career, and we are here to support you every step of the way. We want you to be successful and fulfilled. Through on-the-job experiences, personalized coaching and our robust learning and development programs, we encourage you – at every level – to grow and develop.
<br><br>
<b>BENEFITS:</b><br>
We offer comprehensive benefits to help you be healthy, build financial security, and balance work and home life. At The Hanover, you’ll enjoy what you do and have the support you need to succeed.
<br><br>
<b>Benefits include:</b><br>
<ul>
<li>Medical, dental, vision, life, and disability insurance</li>
<li>401K with a company match</li>
<li>Tuition reimbursement</li>
<li>PTO</li>
<li>Company paid holidays</li>
<li>Flexible work arrangements</li>
<li>Cultural Awareness Day in support of IDE</li>
<li>On-site medical/wellness center (Worcester only)</li>
<li>Click here for the full list of Benefits</li>
</ul>
<b>EEO statement:</b><br>
The Hanover values diversity in the workplace and among our customers. The company provides equal opportunity for employment and promotion to all qualified employees and applicants on the basis of experience, training, education, and ability to do the available work without regard to race, religion, color, age, sex/gender, sexual orientation, national origin, gender identity, disability, marital status, veteran status, genetic information, ancestry or any other status protected by law.
<br><br>
Furthermore, The Hanover Insurance Group is committed to providing an equal opportunity workplace that is free of discrimination and harassment based on national origin, race, color, religion, gender, ancestry, age, sexual orientation, gender identity, disability, marital status, veteran status, genetic information or any other status protected by law.”
<br><br>
As an equal opportunity employer, Hanover does not discriminate against qualified individuals with disabilities. Individuals with disabilities who wish to request a reasonable accommodation to participate in the job application or interview process, or to perform essential job functions, should contact us at: HRServices@hanover.com and include the link of the job posting in which you are interested.
<br><br>
<b>Privacy Policy:</b><br>
To view our privacy policy and online privacy statement, click here.
<br><br>
<b>Applicants who are California residents:</b> To see the types of information we may collect from applicants and employees and how we use it, please click here.
<br><br>
<b>Compensation:</b><br>
The target hiring range for this role may vary based on geographic location and other factors, including merit or performance, demonstrated proficiency, skills for the role, education, travel requirements, and experience. Additional compensation may include an annual bonus (which could take the form of a general bonus, sales incentive, or short-term incentive), long-term incentive or spot recognition awards. The posted range reflects our ability to hire at different position titles and levels depending on background and experience.

Regional General Adjuster (Large Loss Commercial Property)

Exodus Recovery Inc.

<p><b>Job Summary:</b></p><p><b>Exodus Recovery, Inc (Exodus)</b> is looking to hire a <i>per diem </i><b>Private Insurance Coordinator.</b></p><p>Private Insurance Biller will provide support to Data Supervisor, Senior Data Specialist, Program Director, clinical staff and Executive team as a lead biller. Execute private insurance for all Exodus Recovery programs. Private Insurance Biller will maintain current data, train staff to read eligibility types, balance bill for PI clients, submit claims, track and follow up with insurance companies, train other billers to accurately bill and collect PI payments, adjudicate claims, travel to other counties to attend county trainings and work with local billing staff. Private Insurance Biller will provide status reports to the Executive Analyst and billing supervisor on current status of all PI claims and payments. Update all information using internal database created in conjunction with the data analyst team. Work as a lead for all reporting and conduct follow up related to private insurance. Heavy follow up, extensive hours on the phone with insurance companies, continued education, and professional development mandatory; stay current and informed of state and federal healthcare changes that apply to billing and HIPAA rules and regulations. This position will be required to travel to other counties and programs on a regular and as needed basis.</p><p><b>PLEASE NOTE: this is an in-office position requiring travel throughout Los Angeles County, and that work hours may vary</b></p><p><b>MINIMUM QUALIFICATIONS:</b></p><ul><li>Requirements: 2- 3 years&rsquo; experience in a customer service oriented position.</li><li>Experience with direct insurance billing for Mental Health Services, familiar with different types of healthcare plans. Strong administrative skills in a healthcare setting. Must be able to work independently without constant supervision. Must be able to travel and have own transportation, will work outside of LA County for different projects as needed.</li><li>Understanding of health insurance billing or claim process must be self-&shy; motivated, comfortable with spending many hours on calls with insurance companies. Must be able to travel regularly to other counties. Must be computer literate with a focus on Word documents, Excel spreadsheets, Speedy Claims and reports, Outlook and able to do Internet searches. Excellent communication and customer service skills are a must.</li></ul><p><b>EDUCATION:</b><br/>High School Diploma or GED. Bachelor&rsquo;s degree or equivalent work experience preferred.</p><p>Pay: $21.00 - $23.00 per hour</p><p>Benefits:</p><ul><li>401(k)</li><li>Employee assistance program</li></ul><p>Application Question(s):</p><ul><li>Do you have a familial or close relationship with a current Exodus employee? If yes, please tell us the employee&rsquo;s name.</li></ul><p>Ability to Commute:</p><ul><li>Los Angeles, CA 90056 (Required)</li></ul><p>Ability to Relocate:</p><ul><li>Los Angeles, CA 90056: Relocate before starting work (Required)</li></ul><p>Work Location: In person</p>

Private Insurance Coordinator

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Special Investigation Unit Investigator III
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Administrative, HR, Business Professionals
</div></div></div></div><div><div><div><div><b>Department: </b>Special Investigations Unit
</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>13060
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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><p>
The Special Investigation Unit Investigator III performs in-depth evaluation of potential fraud &amp; abuse cases and develops complex investigations that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for fraud, waste &amp; abuse. In addition, this position is responsible for building the investigative approach and provide leadership for Investigators through mentoring, on-site audit leadership and hands-on training of investigative techniques.</p><br>
<p></p>
<div>Responsible for in-depth investigations requiring subject matter expertise for suspected provider, pharmacy, employer or member fraud or abuse across all products at L.A. Care Health Plan. Ensures adherence to L.A. Care's policies and procedures for its various product offerings. Conducts investigation-related training. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</div>
</div></div><div><div><div>
Duties</div>
</div><div><p>
Investigates allegations and complex issues pertaining to potential health care fraud by providers or members. Makes potential fraud &amp; abuse determinations by utilizing a variety of sources including data analytics to detect unusual billing. Proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media) and initiates appropriate action. Writes comprehensive investigatory/fact-finding reports and summaries documenting interviews and findings. Reviews information contained in standard claims processing system files (e.g. claims history, provider files) to determine provider billing patterns and detect potential fraudulent or abusive billing practices or vulnerabilities in Medi-Cal/Medicare policies and initiates appropriate action. This position is a leader at onsite audits as assigned in conjunction with investigation development. Completes investigations after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare &amp; Medicaid Services (CMS), Department of Justice (DOJ) or local police). Participates at hearings/appeals and can testify as a witness in court proceedings. Initiates the process with L.A. Care&rsquo;s Recovery Services for recoupment of overpaid monies.</p><br>
<p></p>
<p>Submits referrals of suspected fraud cases within mandated period of time as required by DHCS and CMS. Prepares and submits investigative report documenting all phases of an investigation. Compiles and maintains various documentation and other reporting requirements while following all confidentiality and security guidelines. Maintains cases referred to law enforcement and responds to requests for information; pursues applicable administrative actions during investigation/case development.</p><br>
<p></p><div>Participates in industry meetings/trainings and is able to effectively share and gather significant information. Develops and maintains strong working relationships with associates and regulators including DHCS, DOJ the FBI, Local Law Enforcement, Prosecutors, etc. Continually enhances investigative skills and understanding of emerging issues and trends impacting the industry.</div><br>
<div></div><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project&rsquo;s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><br>
<div></div>
<div>Perform other duties as assigned.</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>Bachelor's Degree in Criminal Justice or Related Field</div><div>
In lieu of degree, equivalent education and/or experience may be considered.</div></div></div><div><div><div>
Education Preferred</div>
</div><div><div>Master's Degree in Criminal Justice or Related Field</div></div></div><div><div><div>
Experience</div>
</div><div><div><b>
Required:</b></div>
<p>Minimum of 5 years of experience in healthcare fraud investigation/detection and/or healthcare related specialty including but not limited to; Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental etc.</p>
<p>Experience conducting fact-finding interviews or investigations to gather information and draw conclusions from various accounts and versions of the same event.</p><br>
<p></p>
<p>Experience managing large amounts of data including pivot tables, complex calculations, and ability to perform comparisons across multiple large data sets</p><br>
<p></p>
<p><b>Preferred:
</b></p><div>Diverse experience as subject matter expert (SME) with multiple specialties including: Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental etc.</div>
</div></div><div><div><div>
Skills</div></div><div><div><br>
<b>Required:</b><br>
Excellent research skills and the ability to support conclusions with documentary evidence.</div><br>
<div></div>
<div>Excellent analytical, problem solving, and resolution skills and the ability to discern the practical application of regulatory and legal requirements.</div><br>
<div></div>
<div>Demonstrated strong organizational skills and the ability to manage multiple demands and priorities.</div><br>
<div></div>
<div>Excellent and effective communication skills, both verbal and written.</div><br>
<div></div>
<div>Proficient computer skills, including computer applications such as MS Word and Excel.</div><br>
<div></div>
<div>Understanding of the vital importance of commitment to excellence and demonstrating a high regard for organizational values.</div><br>
<div></div>
<div>Ability to maintain in-depth working knowledge of fraud investigation techniques and mentor less experienced team members.</div><br>
<div></div>
<div><b>Preferred:
</b></div><div>Proficiency with Access.</div>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Accredited Health Care Fraud Investigator (AHFI)</div><div>
Certified Fraud Examiner (CFE)</div><div>
Certified Professional Coder (CPC) designation by the American Academy of Professional Coders</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><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>Medical Coding, Pharmacy, Behavioral Health, Clinic, Hospice, Healthcare</p></div></div></div><div></div>

Special Investigation Unit Investigator III

Amity Foundation

<div>
 <strong>
  Amity Foundation
 </strong>
 , an internationally acclaimed Teaching, and Therapeutic Community is seeking compassionate and enthusiastic individuals with a desire to teach, learn and join our community as a
 <strong>
  ECM Data Entry Clerk.
 </strong>
 This groundbreaking opportunity will allow you to work with our prison and re-entry programs helping the community and will also enhance your training and experience in the field.
 <strong>
  About Amity:
 </strong>
 Amity Foundation is a safe place where people can change in an environment that fosters trust; where new values can be formed; responsibility developed, and lasting relationships built. Amity is dedicated to the inclusion and habilitation of people marginalized by addiction, homelessness, trauma, criminality, incarceration, poverty, racism, sexism, and violence. Amity is committed to research, development implementation, and dissemination of information regarding community building.
 <em>
  Remembrance, Resolution, Reconciliation, Restoration, Renewal
  <br/>
  <br/>
 </em>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 The Data Entry Clerk for the Enhanced Care Management (ECM)-Community Supports (CS) program is responsible for the data entry of this project. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions. ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for students. The Quality Assurance Specialist is vital to the ECM program administration and compliance.
 <br/>
 <br/>
 <strong>
  What You Will Do
  <br/>
  <br/>
 </strong>
 <strong>
  Essential Duties:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Enter new ECM student/member demographics, referral information, admission dates, and required program fields into the EHR system with a high level of accuracy.
  </li>
  <li>
   Upload all required documentation (e.g., consents, eligibility verification, ROI, care plans, assessments, outreach logs) into the correct EHR categories.
  </li>
  <li>
   Maintain naming conventions and filing standards to ensure documents are easily accessible for audits and quality checks.
  </li>
  <li>
   Monitor incoming referrals and promptly initiate EHR entries in alignment with MCP timelines.
  </li>
  <li>
   Prepare reports from the electronic health record system for the timely submission of claims, working closely with the accounting department to ensure proper reimbursement for services.
  </li>
  <li>
   Ensure all admission and enrollment data meet Medi-Cal, DHCS, and individual MCP (IEHP, LA Care, Kaiser, Molina, ILS, Blue Shield, Anthem Blue Cross&hellip;etc.) requirements.
  </li>
  <li>
   Track missing documents and follow up with Case Managers to secure outstanding forms or signatures.
  </li>
  <li>
   Verify accuracy of admission dates, program flags, and authorization data to ensure billing readiness.
  </li>
  <li>
   Support QA audits by ensuring documentation is uploaded in advance of internal and MCP audits.
  </li>
  <li>
   Ensure complete client charts within agency&rsquo;s Electronic Health Record (EHR).
  </li>
  <li>
   Communicate with Case Managers, LVNs, CHWs, BHCMs, and QA staff to resolve discrepancies in documentation or referrals.
  </li>
  <li>
   Monitor workload dashboards and notify leadership of delays, bottlenecks, or recurring issues with referral data.
  </li>
  <li>
   Generate simple reports or summaries on completed uploads or pending items upon request.
  </li>
  <li>
   Answer phones, respond to emails, and interface with others in a professional and courteous manner.
  </li>
  <li>
   Attend workshops, meetings, and trainings as requested by supervisor.
  </li>
  <li>
   Perform any other assigned tasks or duties
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  What You Will Bring
  <br/>
  <br/>
 </strong>
 <strong>
  Education and Experience:
  <br/>
  <br/>
 </strong>
 <strong>
  Required
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   High School diploma or GED required, and (2) years related experience in a data entry or administrative role, preferably within a healthcare or social services setting.
  </li>
  <li>
   Excellent attention to detail and the ability to manage complex information with high accuracy.
  </li>
  <li>
   Strong organizational and time-management skills.
  </li>
  <li>
   Proficiency with data entry, electronic health record systems, and Microsoft Office suite.
  </li>
  <li>
   Effective written and verbal communication skills.
  </li>
  <li>
   Experience with managing reports and reviewing services prior to claim submission in a behavioral healthcare setting is a plus.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Certifications or Licenses:
 </strong>
  Required:
 <br/>
 <br/>
 <ul>
  <li>
   Driver&rsquo;s License
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Skills/Abilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Proficient in EHR systems (e.g., Exym, Epic) or ability to learn new platforms quickly.
  </li>
  <li>
   Strong typing accuracy and speed; experienced in digital document uploading, naming conventions, and file organization.
  </li>
  <li>
   Familiarity with Microsoft Office (Excel, Word), PDFs, and cloud-based storage systems.
  </li>
  <li>
   Ability to multi-task, identify problems, provide recommendations to management teams, and implement any applicable systems.
  </li>
  <li>
   Ability to work constructively with diverse people and with parties that may have divergent perspectives and interests.
  </li>
  <li>
   Ability to clearly express concepts and direction, both orally and in writing, and to prepare complex reports, policies, and procedures.
  </li>
  <li>
   Understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
  </li>
  <li>
   Strong oral and written communication skills.
  </li>
  <li>
   Ability to troubleshoot basic digital file issues (e.g., file formatting, upload problems, missing metadata).
  </li>
  <li>
   Strong attention to detail and ability to maintain high accuracy while handling repetitive tasks.
  </li>
  <li>
   Consistent ability to meet deadlines, follow structured workflows, and work independently with minimal supervision.
  </li>
  <li>
   Excellent record-keeping and document-tracking abilities, especially in fast-paced environments with multiple referrals.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  What We Bring
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Medical, Dental, Vision.
  </li>
  <li>
   Paid vacation, sick time, &amp; holidays.
  </li>
  <li>
   401K, HSA, &amp; Life insurance programs.
   <br/>
   <br/>
  </li>
 </ul>
 Additional information
 <br/>
 <br/>
 <strong>
  ADA Information
  <br/>
  <br/>
 </strong>
 <strong>
  Physical Requirements:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Faculty must frequently lift and/or move up to 50 pounds.
  </li>
  <li>
   Frequently required to sit and/or stand for extended periods of time.
  </li>
  <li>
   Frequently required to type for extended periods of time.
  </li>
  <li>
   Occasionally required to reach, walk, climb, pull, push, grasp, stretch, stoop.
  </li>
  <li>
   Frequently required to talk, hear, see, and use repetitive motions.
  </li>
  <li>
   Frequently able to communicate in verbal and written form.
  </li>
  <li>
   Frequently able to use all types of vision, such as close vision, distance vision, color vision, peripheral vision, and depth perception, to complete daily tasks.
  </li>
  <li>
   Required to wear comfortable and office appropriate clothes.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Mental Demands
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Ability to change direction as priorities shift.
  </li>
  <li>
   Ability to thrive in an environment that requires one to adapt to changing circumstances.
  </li>
  <li>
   Ability to professionally work under pressure with difficult or temperamental students &amp; faculty.
  </li>
  <li>
   Ability to handle mental and emotional stress related to the position.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Work Conditions
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Generally, in an indoor office setting.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Environmental Conditions
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   The noise level in the work environment is moderate but can be loud.
  </li>
  <li>
   The temperature in the work environment is usually moderate to cool but can be cold or hot.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Travel
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   May travel locally by vehicle.
   <br/>
   <br/>
  </li>
 </ul>
 $24 - $26 an hour
</div>


Data Entry Clerk- ECM (ONSITE - Los Angeles)

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