- Evolent (Tallahassee, FL)
- …subject matter expert. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls) with requesting ... physicians or ordering providers, when available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with… more
- Sumitomo Pharma (Tallahassee, FL)
- …portfolio, including hub services (benefits investigation, prior authorization, and appeals support), field reimbursement managers, Patient Assistance Program (PAP) ... and copay assistance programs + Drive **data-driven decision-making** , leveraging patient insights and real-world evidence to refine program effectiveness, + **Vendor Oversight** + Oversee **third-party service providers** , ensuring high-quality execution… more
- Trinity Health (Fort Lauderdale, FL)
- …Business Service (PBS) centers, including analysis of clinical documentation, assisting in appeals , root cause analysis and tracking as needed. 6. Educates clinical ... staff on need for accurate and complete documentation to ensure revenue optimization and integrity. Educate clinical staff on need for accurate and complete documentation to ensure revenue optimization and integrity. Perform outpatient clinical documentation… more
- Elevance Health (Miami, FL)
- …a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any ... embassy located in or outside of the US. + Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. + Additional experience may be required by State contracts or regulations if… more
- Ascension Health (Jacksonville, FL)
- …+ Develop strategy and processes to reduce denials and audits. + Assist with appeals and length of stay market initiatives. + Utilize hospital data sources to ... identify & analyze patterns of over or under-utilization of services, quality metrics and collaborate with appropriate stakeholders to help achieve those goals. **About Ascension St. Vincent's Hospitals (Riverside, Southside, Clay, and St. Johns)** St.… more
- Intermountain Health (Tallahassee, FL)
- …updates to charging/coding/NCCI regulations and/or errors, and regarding audits and appeals , to facilitate corrective action planning for improved processes. 7. ... Complies with all CMS, Federal and State regulations, and payor guidelines, and ensures consistent and compliant application with charge/coding capture, charge editing, and audit and reimbursement practices. Researches and collaborates on regulation updates to… more
- MyFlorida (Tallahassee, FL)
- …tribunals, handling everything from evidence review to trial representation and appeals . + Oversee a large caseload of administrative, state, and federal ... civil cases managed by outside counsel, developing comprehensive legal strategies, coordinating discovery, and reviewing pleadings. + Review, analyze, and draft proposed legislation, ensuring departmental policies and procedures are legally sound, and… more
- CHS (Clearwater, FL)
- …and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS. Participates in Product Development ... and Sales processes, including participation when requested in prospective client presentations, regulatory reviews and contracting of vendors. **Primary Performance Expectations:** Performance review for the Claims Manager is ongoing, with formalized reviews… more
- Akumin (West Palm Beach, FL)
- …procedures from insurance companies. Provides supporting documentation for all insurance appeals and denials. + Other duties as assigned. **Position Requirements:** ... + High School Diploma or equivalent experience. + CPR Certification. + 1 year in medical/hospital setting + **Interpersonal Skills:** Relationship building skills to work with all functional units of the organization effectively. Experience in working with… more
- AdventHealth (Tampa, FL)
- …the mortality/risk adjustment reviews when assigned. . Assists with post-payment DRG appeals . . Maintains 98% accuracy rate. . Assists manager in maintaining goals ... for accounts discharged not final billed. . Assists in reviewing and correcting any information for the Agency for Healthcare Administration (AHCA). Qualifications **T** **he expertise and experiences you'll need to succeed:** + High school grad and technical/… more