healthcare claims specialist

Renown Health

<div><div><div><div><div><div><div><div><div><p><b>Position Purpose</b></p><br>
</div></div><br>
<div><div><div><div><div><div><div><div><div><div><p>The Insurance and Claims Specialist will review and correct claim errors ensuring accurate, timely claim submission and account follow-up to assigned payors and reimbursement on first claim submitted. The Specialist will appeal healthcare claims denied by third-party payors to obtain reimbursement and handle difficult, hard to collect accounts that have been deemed by the insurance company as unpayable. The Specialist will conduct analysis and resolve incorrect reimbursement issues and credit balance resolution with payors. This position is responsible to know all state/federal regulations that relate to contracts and to the appeal process and/or government payor billing and follow-up regulations to include CCI, LCD/NCD and medical necessity rules.</p><br>
</div></div><br>
</div></div></div></div><br>
</div></div></div></div><br>
</div></div><p></p><div><div><div><div><p><b>Nature and Scope</b></p><br>
</div></div><br>
<div><div><div><div><div><div><div><div><div><div><p>The Insurance and Claims Specialist is responsible for:</p><br>
<p></p><ul><li>Work assigned Work Queues to correct errors, ensuring accurate claims and reimbursement on first claim submission.</li></ul>
<ul><li>Audit denials and payment variances to determine root cause and correction as required.
</li></ul><ul><li>Auditing payment variances ensuring appropriate reimbursement.</li></ul>
<ul><li>Provide specific and in depth contract knowledge to ensure maximum reimbursement of healthcare claims.</li></ul>
<ul><li>Resolve credit balances by reviewing payments, adjustments or transfers correcting the patient account to reflect an accurate account receivable balance.
</li></ul><ul><li>Work with leadership and other internal departments to improve processes, increase accuracy, create efficiencies and decrease denials to achieve the overall goals of Renown Health.</li></ul>
<ul><li>Maintain a current knowledge of CPT/HCPCS, ICD, DRG, HCFA forms, ability to manipulate and analyze 837 and all other HIPAA transaction sets.</li></ul><br>
<p></p><p>This position is required to operate within policy and procedural guidelines that will ensure accurate accounts receivable reporting and is compliant with policy and procedural guidelines consistent with Renown Health goals and objectives.</p><br>
<p></p><p>This position does not provide patient care.<br>
</p></div></div><br>
</div></div></div></div><br>
</div></div></div></div><br>
<div><div><div><div><div><div><p><b>Disclaimer</b></p><br>
</div></div><br>
<div><div><div><div><div><div><p>The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.</p><br>
</div></div><br>
</div></div></div></div><br>
</div></div></div></div><br>
</div></div><p></p><div><div><div><div><p><b>Minimum Qualifications</b><br>
Requirements - Required and/or Preferred</p><br>
</div></div><br>
<div><div><div><div><div><div><div><div><div><div><p><b>Name</b></p><br>
</div><div><p><b>Description</b></p><br>
</div></div><br>
<div><div><p>Education:</p><br>
</div><div><p>Must have working-level knowledge of the English language, including reading, writing and speaking English. Associates degree preferred.</p><br>
</div></div><br>
<div><div><p>Experience:</p><br>
</div><div><p>One year healthcare billing office experience with extensive knowledge of healthcare billing, government and third party payor requirements. Associate degree or certification in accredited billing certification may be accepted in lieu of years of experience.</p><br>
</div></div><br>
<div><div><p>License(s):</p><br>
</div><div><p>None.</p><br>
</div></div><br>
<div><div><p>Certification(s):</p><br>
</div><div><p>None.</p><br>
</div></div><br>
<div><div><p>Computer / Typing:</p><br>
</div><div><p>Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.</p><br>
</div></div><br>
</div></div></div></div><br>
</div></div></div></div><br>
</div></div></div></div></div></div><br>
<p></p>Location: Renown Health &middot; 100620 Hospital Billing Services<br>
Schedule: Full Time - Eligible for Benefits, Day, 8am-4:30pm</div>

Insurance and Claims Specialist - Hybrid

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>Data Analyst</div><div><b>
Working Title: </b>Senior Claims Specialist</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$41,102 - $59,518</div><div><b>
Office Location: </b>Remote within North Carolina</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Senior Claims Specialist to join our team! The Senior Claims Specialist performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.</li><li>
Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.</li><li>
Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.</li><li>
Identify adjudication errors, provider billing errors, and the need for technical assistance.</li><li>
Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.</li><li>
Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.</li><li>
Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications</b></div><div></div><div><br>
Required:</div><div><ul><li>
High School Diploma/GED and two (2) years of experience in the claims processing or billing or medical coding field; OR</li><li>
Equivalent combination of education/experience.</li><li>
Must have a valid driver&rsquo;s license</li><li>
Must reside within North Carolina</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Associate&rsquo;s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.)</li></ul></div><div><ul><li>
 Hospital claims experience and knowledge</li><li>
 Experience in the areas of physical health claims processing or medical coding</li><li>
 Experience working with Managed Care billing software</li><li>
Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.</li></ul></div><p></p><div><b><br>
Deadline for Application:</b> Open Until Filled</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div>

Senior Claims Specialist

SmithRx

<div><p><b>Who We Are:</b></p>
<p>
SmithRx is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service. With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.</p>
<p>
We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:</p>
<ul>
<li><b>Integrity:</b> Our purpose guides our actions and gives us confidence in the path ahead. With unwavering honesty and dependability, we embrace the pressure of challenging the old and exemplify ethical leadership to create the new.</li>
<li><b>Courage:</b> We face continuous challenges with grit and resilience. We embrace the discomfort of the unknown by balancing autonomy with empathy, and ownership with vulnerability. We boldly challenge the status quo to keep moving forward&mdash;always.</li>
<li><b>Together: </b>The success of SmithRx reflects the strength of our partnerships and the commitment of our team. Our shared values bind us together and make us one. When one falls, we all fall; when one rises, we all rise.</li>
</ul>
<p><b>Job Summary:</b></p>
<p>
As a Claims Specialist, you will play a pivotal role in ensuring exceptional member satisfaction and operational efficiency within our dynamic Health-Tech environment. You will be responsible for the accurate and timely processing of complex non-electronically submitted claims, including direct member reimbursements and commercial out-of-network claims. Beyond routine processing, this role demands proactive problem-solving, acting as a critical liaison between members and our clinical team for denied reimbursements, and initiating prior authorization processes to ensure seamless continuity of care. You will leverage your expertise to uphold claims integrity, drive process improvements, and provide essential cross-functional support to our account management, member support, and other customer success teams, contributing directly to our mission of transforming healthcare.Projects and other tasks that may arise and be assigned as needed.</p>
<p><b>
What you will do:</b></p>
<ul>
<li>Responsible for ensuring timely completion of non-electronically processed claims such as direct member reimbursement claims and commercial out-of-network claims.</li>
<li>Ensure claims approvals and/or denials are made in accordance with company practices and procedures. Timely execution on member communications at scale, including mail-outs through our third-party mail vendor.</li>
<li>Maintain reimbursement queue to meet the department's SLA's. Completion of assigned claim cases in accordance with daily expectations.</li>
<li>Sustain integrity of all existing claims processes by ensuring all process documentation is up to date.</li>
<li>Participate in process improvement and quality assurance opportunities.</li>
<li>Collaborate and provide cross-functional support to account management, member support, and other customer success teams.</li>
<li>Act as a liaison between the clinical team and the member for denied reimbursements, initiating the prior authorization (PA) process to ensure proactive member support.</li>
<li>Participate in internal meetings to help support initiatives and projects.</li>
<li>Ability to prioritize and complete high-volume cases/claims.</li>
</ul>
<p><b>What you will bring to SmithRx:</b></p>
<ul>
<li>2+ year of experience in a healthcare claims role, preferably in a pharmacy setting or licensed as a pharmacy technician.</li>
<li>Prior working knowledge of medical or pharmacy claims processing.</li>
<li>Excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.</li>
<li>Microsoft Excel skills required.</li>
<li>Impeccable attention to detail and accuracy in work.</li>
<li>Strong problem solving, written and verbal communication, and interpersonal skills</li>
<li>Ability to work independently as well as part of an extended, cross-functional team</li>
<li>Self-driven, results-oriented work ethic with a positive outlook</li>
<li>Ability to take initiative with little to no direction</li>
</ul>
<p><b>What SmithRx Offers You:</b></p>
<ul>
<li>Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&amp;D Insurance</li>
<li>3 Weeks Paid Time Off</li>
<li>Paid Company Holidays</li>
<li>Paid Parental Leave Benefits</li>
<li>Flexible Spending Benefits</li>
<li>401(k) Retirement Savings Program</li>
<li>Short-Term and Long-Term Disability</li>
<li>Wellness Benefits</li>
<li>Commuter Benefits</li>
<li>Employee Assistance Program (EAP)</li>
<li>Well-stocked Kitchen In Office Locations</li>
<li>Professional Development and Training Opportunities</li></ul></div>

Claims Operations Specialist

AdaptHealth

<div>Description:
<p><b>
AdaptHealth Opportunity &ndash; Apply Today!</b></p><p>
At AdaptHealth we offer full-service home medical equipment products and services to empower patients to live their best lives &ndash; out of the hospital and in their homes. We are actively recruiting in your area. If you are passionate about making a profound impact on the quality of patients&rsquo; lives, please click to apply, we would love to hear from you.</p><p><b>
PAP Specialist</b></p><p>
The PAP Specialist has a broad range of responsibilities including accurate and timely data entry, understanding, and selecting inventory and services in key databases, communicating with referral sources, and appropriately utilizing technology to notate patient information/communication. Intake Specialist&rsquo;s schedules can vary based on the need of the branch. Hours can range anywhere between 8am and 7pm 7 days/week.</p><p>
Responsible for ensuring customers receive PAP equipment by scheduling an appointment for the customer to come in to pick up equipment and receive proper instruction on how to best use the equipment. Explains customers financial responsibility and ensure payment.</p><p>
PAP Specialists are responsible for preparing and submitting audit paperwork for Medicare and other insurance claims to ensure continued compliance with healthcare guidelines. The PAP Specialist will accurately respond to claim audits and communicate audit results in such a way to provide education and appropriate process changes that directly impact the daily functions of AdaptHealth.</p><p>
Responsible for monitoring, communicating, and managing all clients on Positive Airway Pressure devices. Responsible for encouraging client compliance with PAP equipment and program.</p><p><b>
Job Duties:</b></p><ul><li>
Develop and maintain working knowledge of current HME products and services offered by the company and all applicable insurance guidelines respecting eligibility for coverage and reimbursement.</li><li>
Is actively involved in team activities, evidenced by participation, mentoring, and training with co-workers</li><li>
Assists in the development and maintenance of reference materials for use by staff and facilitates the sharing of information</li><li>
Develops relationships with branches, other teams to accomplish goals</li><li>
Participates in monthly team meetings and trainings</li><li>
Responsible for entering data in an accurate manner, into database including although not limited to payer, authorization requirements, coverage limitations and status of any requalification</li><li>
Collaborates with physician offices, AdaptHealth sales and support staff to ensure timely receipt of documentation as well as educating, as necessary.</li><li>
Identify trends and providing feedback and education to internal and external customers on compliant documentation requirements for services provided.</li><li>
Maintain patient confidentiality and function within the guidelines of HIPAA</li><li>
Completes assigned compliance training and other educational programs as required</li><li>
Maintains compliant with AdaptHealth&rsquo;s Compliance Program</li><li>
Other duties as assigned.</li></ul>
Requirements:
<p><b>
Minimum Job Qualifications:</b></p><ul><li>
High School Diploma or equivalent</li><li>
One (1) year work related experience in health care administrative, financial, or insurance customer services, claims, billing, call center or management regardless of industry.</li><li>
Senior level requires two (2) years of work-related experience and one (1) year of exact job experience.</li><li>
Exact job experience is considered any of the above tasks in a Medicare certified HME, Diabetic, Pharmacy, or home medical supplies environment that routinely bills insurance.</li></ul><p>
AdaptHealth is an equal opportunity employer and does not unlawfully discriminate against employees or applicants for employment on the basis of an individual&rsquo;s race, color, religion, creed, sex, national origin, age, disability, marital status, veteran status, sexual orientation, gender identity, genetic information, or any other status protected by applicable law. This policy applies to all terms, conditions, and privileges of employment, including recruitment, hiring, placement, compensation, promotion, discipline, and termination.</p></div>

PAP Specialist

Amerit Consulting

<div>
 <p>
  <strong>
   <u>
    OVERVIEW:
   </u>
  </strong>
 </p>
 <p>
  <strong>
   Our client, a US Fortune 50 organization and a leading provider of Healthcare and Health Insurance services
  </strong>
  , seeks an accomplished
  <strong>
   Medical Claims Specialist
  </strong>
  .
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    IMPORTANT NOTES: REMOTE / WORK-FROM-HOME RELATED:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   <strong>
    This will be a Remote role.
   </strong>
  </li>
  <li>
   <strong>
    Equipment's will be provided.
   </strong>
  </li>
  <li>
   MUST have high-speed wired Internet connection. Wi-Fi / Wireless connections are not allowed.
  </li>
  <li>
   MUST have a reliable home-office environment.
  </li>
  <li>
   <strong>
    Payrate would be $18.15 per hour. The worker must also receive an additional $5.55 per hour payment in lieu of benefits. Total hourly Pay rate would be $23.70 per hour.
   </strong>
  </li>
  <li>
   <strong>
    Training Shift Hours: 40 hours per week | 08:00am to 4:30pm (Eastern Time).
   </strong>
  </li>
  <li>
   <strong>
    Training will be 5-6 weeks.
   </strong>
  </li>
  <li>
   <strong>
    After training, the candidates may choose to flex start time of 6:00 AM to 10:00 AM (Eastern Time).
   </strong>
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Client will be considering candidates MUST sit within 50 miles of below location (Please apply accordingly):
   </u>
  </strong>
 </p>
 <ul>
  <li>
   Dennison, TX
  </li>
  <li>
   Atlanta, GA
  </li>
  <li>
   Midland/Columbus, GA
  </li>
  <li>
   Indianapolis, INDIANA
  </li>
  <li>
   Louisville, KY
  </li>
  <li>
   Gilbert, MN
  </li>
  <li>
   St Louis, MO
  </li>
  <li>
   Winston-Salem, NC
  </li>
  <li>
   Cincinnati, OH
  </li>
  <li>
   Columbus, OH
  </li>
  <li>
   Mason, OH
  </li>
  <li>
   Nashville, TN
  </li>
  <li>
   Norfolk, VA
  </li>
  <li>
   Richmond, VA
  </li>
  <li>
   Roanoke, VA
  </li>
  <li>
   Baltimore, MD
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Responsibilities:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   This is an entry level position in the NGS Appeals Department that reviews, analyzes and
   <strong>
    processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A &amp; B)
   </strong>
   related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
  </li>
  <li>
   Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
  </li>
  <li>
   Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
  </li>
  <li>
   The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements.
  </li>
  <li>
   As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.
  </li>
  <li>
   Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
  </li>
  <li>
   Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
  </li>
  <li>
   The analyst may serve as a liaison between grievances &amp; appeals and /or medical management, legal, and/or service operations and other internal departments.
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Required Qualifications:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   <strong>
    Must have High School Diploma or GED.
   </strong>
  </li>
  <li>
   <strong>
    Must have 3-4 years&rsquo; experience working with Medical Claims, grievances and appeals, Medicare, Part A OR PART B.
   </strong>
  </li>
  <li>
   <strong>
    Familiarity with medical terminology, demonstrated business writing proficiency.
   </strong>
  </li>
  <li>
   Must have strong understanding of provider networks, the
   <strong>
    medical management process
   </strong>
   ,
   <strong>
    claims processing
   </strong>
   .
  </li>
  <li>
   Must be proficient handling
   <strong>
    high volume
   </strong>
   <strong>
    inbound calls
   </strong>
   .
  </li>
  <li>
   Must have background in
   <strong>
    following up with insurance providers
   </strong>
   .
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <em>
    I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
   </em>
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Recruiter Contact Info
  </strong>
 </p>
 <p>
  Jatin Rattan
 </p>
 <p>
  E-mail: jatin.rattan@ameritconsulting.com
 </p>
 <p>
  www.ameritconsulting.com
 </p>
 <p>
  <br/>
 </p>
 <p>
  <em>
   I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
  </em>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Company Overview:
  </strong>
 </p>
 <p>
  Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally; as well as small to mid-sized organizations on a local &amp; regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients&rsquo; businesses forward.
 </p>
 <p>
  <br/>
 </p>
 <p>
  Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
 </p>
 <p>
  <br/>
 </p>
 <p>
  This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.
 </p>
</div>


Medical Claims Specialist

Caloptima

<div><div><b>Grievance Resolution Specialist Sr (Provider Resolution)</b><br>
<br>
<b>CalOptima</b></div><br>
<b>
Join Us in this Amazing Opportunity</b><br>
<br>
<b>The Team You'll Join</b><br>
<br>
We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.<br>
<br>
<b>More About the Opportunity</b>
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We are hoping you will join us as a <b>Grievance Resolution Specialist Sr (Provider Resolution)</b> and help shape the future of healthcare where you'll be an integral part of our <b>Grievance &amp; Appeals </b>team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be <b>Full Telework</b>.
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<ul><li><i>If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.</i>
</li></ul><br>
You will coordinate the overall process of complaint resolution, responding to all verbal and written complaints from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. You will have frequent external contact with members and families, health care providers, organizations and regulators. In addition, you will frequently interact with internal contacts in Claims Administration, Customer Service, Provider Relations, Contracting, Pharmacy Management, Third-Party Administrators, Medical Management, health networks and other resources to identify the factors necessary for optimal resolution of complaints. You will be responsible for processing complex cases requiring additional research or problem-solving. You will process 1st and 2nd Level provider appeals in accordance with Department of Health Care Services (DHCS) and Centers for Medicare &amp; Medicaid Services (CMS) guidelines and regulations. Together, we are building a stronger, more equitable health system.
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<b>Your Contributions To the Team:</b>
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<ul><li>75% - Program Support
<ul><li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Develops and maintains adequate information systems to assure timely and effective data collection, summarization, integration and reporting, including case creation, management and events/activity tracking.</li>
<li>Ensures compliance with CalOptima Health's Grievance Policy and timely case resolution, initiates and coordinates referrals to the Quality Improvement department as necessary and facilitates response to members according to policy.</li>
<li>Handles escalated issues from providers, as well as internal and external customers.</li>
<li>Gathers pertinent information regarding complaints, including member or provider concerns, claims payments, billing reimbursements, supporting information related to initial decisions, new information supporting complaints and supplemental information required to evaluate complaints and regulatory requirements.</li>
<li>Coordinates and participates in case discussions with operational experts to result in a final case disposition.</li>
<li>Reviews government claim cases and determines resolution and recommendation based on researched claims, Provider Dispute Resolution (PDR) and 2nd Level appeal analyses.</li>
<li>Evaluates case details related to member or provider complaints and makes appropriate decisions based on information provided and research conducted.</li>
<li>Provides a summary of GARS cases requested by Legal Affairs or other departments.</li>
<li>Provides subject matter expertise and trains new and existing staff as needed.</li>
<li>Assists with case assignment, assumes cases assignments per business needs and monitors the daily operations for member and provider complaints, ensuring compliance with the implementation of the decision.</li>
<li>Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.</li>
<li>Oversees resolution letters for accuracy of information and appropriate decisions.</li>
<li>Meets performance measurement goals for GARS.</li>
Supports with provider appeals audits by reviewing findings, gathering and organizing requested materials and completing rebuttals.<br>
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</li></ul></li><li>20% - Administrative Support
<ul><li>Participates in meetings regarding case assignment issues and collaborates with cross-department teams to maintain current knowledge of organizational processes and guidelines to effectively resolve cases.</li>
<li>Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.</li>
<li>Responds to routine provider inquiries via phone and assists with provider appeals resolution inquiries.</li>
<li>Tracks and trends provider appeals and claims issues.</li>
Supports all department initiatives in improving overall efficiency.<br>
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</li></ul></li><li>5% - Completes other projects and duties as assigned.
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<b>Do You Have What the Role Requires?</b><br>
<ul>
<li>High school diploma or equivalent PLUS 3 years of experience with Provider Non-Contracted Medicare Post-Service appeals and denials required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.<br>
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<li>3 years of experience with PDR in Medicare and Medi-Cal in Professional, Institutional, Outpatient, Ancillary, Coordination of Benefits and Government Cases required.
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</li><li>Experience with Medicare or Medi-Cal provider appeals and denials process required.<br>
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<li>Experience in health care practice standards, for both government and commercial plans required.<br>
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<li>Experience with claims administration required.</li>
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<b>You'll Stand Out More If You Possess the Following:</b><br>
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<li>Associate's degree in health care administration or related field.<br>
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<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).</li>
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<b>What the Regulatory Agencies Need You to Possess?</b><br>
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<li>N/A</li>
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<b>Your Knowledge &amp; Abilities to Bring to this Role:</b><br>
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
</li><li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
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<b>Your Physical Requirements (With or Without Accommodations):</b><br>
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
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<b>Ways We Are Here For You</b><br>
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul><li>Our current hiring range is: Pay Grade: <b>306 - $58,205 - $90,217 ($27.98 - $43.3736).
</b><ul><li><b><i>The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.</i></b><br>
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</ul></li></ul></li><li>This position is approved for <b>Full Telework </b><i>(**If the position is Telework, it is eligible in California only**)</i>
</li><li>A <b>comprehensive benefits package</b>
</li><li>CalPERS pension program and additional retirement packages.
</li><li>Additional benefits and perks including:
<ul><li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul></li></ul><br>
<b>Our Work Environment:</b><br>
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If located at the 500, 505 Building or a remote work location:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul><br>
If located at PACE:<br>
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
If located in the Community:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
</li><li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
<b>Why Join Us?</b><br>
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We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.<br>
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<b>What's Your Next Step?</b><br>
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All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is <b>April 1, 2026 at </b><b>9:00 PM (PST). </b><b>We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.</b>
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<b>Our Commitment to You</b><br>
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<b>Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.</b><br>
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If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.<br>
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We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.
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<i>CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.</i><br>
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<i>CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.</i><i>
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<i>If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.</i><br>
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<b>To apply, please visit: </b><b>https://jobs.caloptima.org/jobs/grievance-resolution-specialist-sr-provider-resolution-505-city-parkway-west-california-united-states</b><br>
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jeid-9f97bae4154ec349812fc00e682610dd</div>

Grievance Resolution Specialist Sr (Provider Resolution)

TriStar Health

<p></p><div><h5 class="jobSectionHeader"><b>Introduction</b></h5><p></p><p>
This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA).</p><p>
Do you want to join an organization that invests in you as a Claims Resolution Specialist? At Parallon, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years.</p><p></p><h5 class="jobSectionHeader"><b>
Benefits</b></h5><p>
Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:</p><ul><li>
Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.</li><li>
Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.</li><li>
Free counseling services and resources for emotional, physical and financial wellbeing<br>
</li><li>
401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)<br>
</li><li>
Employee Stock Purchase Plan with 10% off HCA Healthcare stock<br>
</li><li>
Family support through fertility and family building benefits with Progyny and adoption assistance.<br>
</li><li>
Referral services for child, elder and pet care, home and auto repair, event planning and more<br>
</li><li>
Consumer discounts through Abenity and Consumer Discounts<br>
</li><li>
Retirement readiness, rollover assistance services and preferred banking partnerships<br>
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Education assistance (tuition, student loan, certification support, dependent scholarships)<br>
</li><li>
Colleague recognition program<br>
</li><li>
Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)<br>
</li><li>
Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.</li></ul><p>
Learn more about Employee Benefits</p><p><b><i>
Note: Eligibility for benefits may vary by location.</i></b></p><p><br>
You contribute to our success. Every role has an impact on our patients&rsquo; lives and you have the opportunity to make a difference. We are looking for a dedicated Claims Resolution Specialist like you to be a part of our team.</p><h5 class="jobSectionHeader"><b>
Job Summary and Qualifications</b></h5><p></p><p><br>
The Claims Resolution Specialist is responsible for applying fundamental knowledge of healthcare revenue cycle practices and procedures as it relates to researching, analyzing, and resolving open insurance claims and balances. This job requires regular outreach to payors.<br>
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<p>In this role you will:</p><br>
<p></p><ul><li>
Conduct follow-up with payors, vendors, and clearinghouse on open insurance claims and balances in compliance with departmental policies and procedures</li><li>
Resubmit primary and secondary claims</li><li>
Identify potential claim issues and escalate to management</li><li>
Review, identify, and resolve payor denials</li><li>
Update patient accounts as appropriate</li><li>
Ensure adjustments are posted timely and correctly for claims that need to be adjusted</li><li>
Resolve claims impacted by payor recoupments and refunds Meet and maintain established departmental performance metrics for production and quality</li><li>
Maintain working knowledge of workflow, systems, and tools used in the department</li></ul><p></p><p><br>
 Qualifications:</p><br>
<p></p><ul><li>
Minimum one-year related healthcare experience preferred.</li><li>
Relevant education may substitute experience requirement.</li><li>
Previous Call Center experience is preferred</li><li>
Virtual employees are required to have high speed wired internet speed 25 MBS Download and 6 MBS Upload</li></ul><p></p><p><b><br>
Parallon</b> provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities.</p><p></p><p>
HCA Healthcare has been recognized as one of the World&rsquo;s Most Ethical Companies&reg; by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.</p><p>
&quot;</p><p></p><p><br>
&quot;Good people beget good people.&quot;- Dr. Thomas Frist, Sr.<br>
HCA Healthcare Co-Founder</p>
<p>We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Claims Resolution Specialist opening. Qualified candidates will be contacted for interviews. <b>Submit your resume today to join our community of caring!</b></p><p><i>
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.</i></p></div>

Claims Resolution Specialist

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