managed care specialist

DataAnnotation

<div>
 We are looking for a
 
 Clinical Appeals Nurse
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $50+ per hour
 </li>
 <li>
 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #medicine
 
</div>

Clinical Appeals Nurse

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Location: This is a full-time telework position requiring 50% travel in and around St Clair, Monroe, Madison, Bond and nearby counties in Illinois. 
Schedule: Standard business hours Monday-Friday 8:00am-5:00pm CST.<h2 class="jobSectionHeader"> 
Position Summary</h2>
The Field Analyst, Case Manager utilizes critical thinking and judgment to collaborate and inform the case management process. The Analyst, Case Manager facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources.<h2 class="jobSectionHeader"> 
Key Responsibilities</h2><ul><li>
Evaluation of Members: Through the use of care management tools and information/data review, conducts comprehensive evaluation of member&rsquo;s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member&rsquo;s benefit plan and available internal and external programs/services.</li><li>
Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.</li><li>
Coordinates and implements assigned care plan activities and monitors care plan progress.</li><li>
Enhancement of Medical Appropriateness and Quality of Care: Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.</li><li>
Identifies and escalates quality of care issues through established channels.</li><li>
Utilizes negotiation skills to secure appropriate options and services necessary to meet the member&rsquo;s benefits and/or healthcare needs.</li><li>
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.</li><li>
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.</li><li>
Engages with colleagues in ongoing team meetings and offers peer mentoring/training.</li><li>
Helps member actively and knowledgably participate with their provider in healthcare decision-making.</li><li>
Monitoring, Evaluation and Documentation of Care: Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.</li></ul><h2 class="jobSectionHeader">
Remote Work Expectations</h2><ul><li>
Candidates must have a dedicated workspace free of interruptions.</li><li>
Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.</li></ul><h2 class="jobSectionHeader"> 

Required Qualifications</h2><ul><li>
2+ years experience in Behavioral Health, Social Services or appropriate related field equivalent to program focus.</li><li>
Must be willing and able to travel 50% of the time in and around St Clair, Monroe, Madison, Bond counties in Illinois.</li><li>
Reliable transportation required. Mileage is reimbursed per our company expense reimbursement policy.</li><li>
Must have 2+ years of experience of electronic documentation experience and Microsoft Office applications.</li></ul><h2 class="jobSectionHeader">
Preferred Qualifications</h2><ul><li>
Demonstrates confidence working remotely as an independent thinker, with the ability to effectively use virtual tools to collaborate and stay connected with team members.</li><li>
Case management and discharge planning experience.</li><li>
Managed Care experience.</li></ul><h2 class="jobSectionHeader">
Education</h2><ul><li>
Bachelor's degree or non-licensed master level clinician required with either degree being in Behavioral Health or Human Services (Psychology, Social Work, Marriage and Family therapy, Counseling)</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$21.10 - $44.99
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 06/05/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Analyst, Case Manager - Field Illinois (St Clair/Monroe/Madison/Bond Counties)

DeCoach Recovery Centre

<div><div>Prior Authorization Specialist
Job Description<div>
DeCoach Recovery is a leading addiction treatment center located in Sharonville, OH, dedicated to providing compassionate care and effective solutions for individuals battling addiction. We are seeking a detail-oriented and experienced Prior Authorization Specialist to join our team.</div>
Job Overview: We are seeking a detail-oriented and energetic Prior Authorization Specialist to join our team. In this vital role, you will manage the authorization process for various medical services, ensuring timely approval from insurance providers. Your expertise will help streamline patient care, reduce delays, and enhance overall satisfaction by navigating complex managed care protocols with precision and professionalism.
Key Responsibilities:<ul><li>
Review and prepare prior authorization requests for medical procedures, medications, and treatments</li><li>
Verify insurance coverage and eligibility through insurance verification processes</li><li>
Accurately code procedures using CPT (Current Procedural Terminology), ICD-9, ICD-10, and ICD coding systems</li><li>
Maintain comprehensive medical records and documentation in compliance with HIPAA regulations</li><li>
Communicate effectively with healthcare providers, insurance companies, and patients to facilitate authorization approvals</li><li>
Track and follow up on pending authorizations to ensure timely responses</li><li>
Stay current with changes in managed care policies, coding standards, and regulatory requirements</li></ul>
Qualifications:<ul><li>
Proven experience in managed care or medical office environments, preferably with prior authorization responsibilities</li><li>
Strong knowledge of medical terminology, medical records management, and medical coding (CPT, ICD-9, ICD-10)</li><li>
Familiarity with insurance verification processes and healthcare billing procedures</li><li>
Experience working in dental or medical offices is highly desirable</li><li>
Excellent organizational skills with attention to detail and accuracy</li><li>
Ability to navigate HIPAA regulations diligently to protect patient confidentiality</li><li>
Office experience demonstrating proficiency with electronic health records (EHR) systems or similar software</li></ul>
Benefits:<ul><li>
Competitive salary based on experience.</li><li>
Medical, Dental, &amp; Vision Heath Insurance</li><li>
Company Paid Life Insurance</li><li>
Affiliated with the STAR program, assist employees in paying off student loans</li><li>
Tuition Reimbursement program</li><li>
Paid Time-Off</li><li>
6 paid Holidays off</li><li>
Opportunities for Advancement</li><li>
Yearly Merit Raises</li></ul>
Join our dedicated team at DeCoach Recovery and contribute to our mission of providing quality addiction treatment services while ensuring financial sustainability through effective revenue cycle management. If you have the required skills and experience, we encourage you to apply and become part of our compassionate and dynamic team.</div> 
8-4:30</div>

Prior Authorization Specialist

FRIENDS OUTSIDE

<div>The CalAIM Medical Billing Specialist is responsible for managing the day-to-day administrative and billing operations related to Enhanced Care Management (ECM) and Community Supports (CS) services. This position supports the organization&rsquo;s CalAIM programming by ensuring accurate claims submission, authorization management, billing compliance, encounter tracking, and reimbursement optimization in accordance with DHCS, Managed Care Plan (MCP), Medi-Cal, and organizational requirements.

The Billing Specialist works closely with care managers, housing support staff, leadership, and Managed Care Plans to ensure timely and compliant billing processes while maintaining accurate records within electronic medical records (EMR/EHR) and billing systems. 
Qualifications:
<ul>
<li>High school diploma or equivalent required; Associate&rsquo;s degree in Medical Billing and Coding, Healthcare Administration, Business Administration, or related field preferred</li>
<li>Minimum of two years of medical billing experience, preferably within Medi-Cal, managed care, behavioral health, or community-based services</li>
<li>Knowledge of CalAIM, Enhanced Care Management (ECM), Community Supports (CS), and Medi-Cal billing practices preferred</li>
<li>Experience with electronic medical record (EMR/EHR) and billing software systems</li>
<li>Understanding of HIPAA regulations, healthcare documentation standards, and claims processing workflows</li>
<li>Strong attention to detail, organizational skills, and ability to manage multiple priorities</li>
<li>Excellent communication and problem-solving abilities</li></ul> 


Key Responsibilities

Billing &amp; Claims Management
<ul>
<li>Submit invoices and claims to Managed Care Plans (MCPs) for ECM and Community Supports services rendered to authorized members</li>
<li>Prepare and submit clean claims electronically or by paper in accordance with payer guidelines, DHCS standards, and MCP requirements</li>
<li>Submit claims utilizing national standard specifications, billing codes, and code sets established by DHCS for ECM and Community Supports services</li>
<li>Ensure maximum reimbursement through accurate billing, coding, and documentation review</li>
<li>Review claims for accuracy, completeness, and compliance prior to submission</li>
<li>Monitor claim status and assigned billing queues daily to support timely payment processing</li>
<li>Manage claims follow-up, denial management, corrections, appeals, and resubmissions as needed</li>
<li>Process and reconcile payer responses, payment postings, and billing reports</li>
</ul>
Authorization &amp; Eligibility Oversight
<ul>
<li>Verify member eligibility with assigned MCPs prior to billing and throughout service enrollment periods</li>
<li>Monitor and maintain ECM and Community Supports authorizations, referrals, and service approvals</li>
<li>Ensure services billed are authorized, medically appropriate, and documented in accordance with DHCS and MCP requirements</li>
<li>Track authorization expiration dates and coordinate reauthorization needs with program staff</li>
</ul>
Documentation &amp; Compliance
<ul>
<li>Maintain accurate and up-to-date data in electronic medical record (EMR/EHR) systems and billing platforms</li>
<li>Ensure documentation supports billed services and complies with ECM and Community Supports standards, including encounter documentation requirements</li>
<li>Maintain strict confidentiality of protected health information in compliance with HIPAA and organizational policies</li>
<li>Support compliance with consent, authorization, and data-sharing requirements related to CalAIM services</li>
<li>Assist with audits, monitoring activities, and reporting requests related to billing and claims processing</li>
</ul>
Coordination &amp; Communication
<ul>
<li>Coordinate with care managers, housing support staff, supervisors, and external partners to obtain necessary documentation and service information</li>
<li>Communicate with MCP representatives regarding claims, authorizations, billing inquiries, and service requirements</li>
<li>Assist staff in resolving documentation deficiencies impacting billing or reimbursement</li>
<li>Participate in interdisciplinary meetings as needed to support program operations and billing integrity</li>
</ul>
Training &amp; Quality Improvement
<ul>
<li>Attend required trainings and maintain current knowledge of CalAIM, ECM, Community Supports, DHCS, and MCP billing requirements</li>
<li>Stay informed on policy, coding, and compliance updates impacting billing practices</li>
<li>Contribute to process improvement efforts to enhance billing accuracy, compliance, and reimbursement outcomes</li></ul></div>

CalAIM Medical Billing Specialist

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10000 managed care specialist jobs Near Me

Clinical Appeals Nurse

Clinical Appeals Nurse

Clinical Appeals Nurse

Clinical Appeals Nurse

Analyst, Case Manager - Field Illinois (St Clair/Monroe/Madison/Bond Counties)

Prior Authorization Specialist

CalAIM Medical Billing Specialist