- Molina Healthcare (Miami, FL)
- **JOB DESCRIPTION** **Job Summary** Performs research and analysis of complex healthcare claims data, pharmacy data, and lab data regarding network utilization and ... cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings. **KNOWLEDGE/SKILLS/ABILITIES** + Develop ad-hoc reports using SQL programming, SQL Server… more
- Prestige Employee Administrators (Tampa, FL)
- …carriers and clients + Collect and maintain plan documentation + Audit plans + Claims assistance + Partner with Accounting to reconcile bill + Benefit system set up ... for new plans + Assist with Open enrollment: + Prepare the system for every client renewal change (benefits and contributions) for Open Enrollment + Update all benefit rules for every client and class for every benefit offered for individual client Open… more
- CVS Health (Tallahassee, FL)
- …in a prepayment environment - Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc. - Researches and prepares cases ... for clinical and legal review. - Documents all appropriate case activity in case tracking system. - Prepares and presents referrals, both internal and external, in the required timeframe. - Facilitates the recovery of company lost as a result of fraud matters.… more
- Commander, Navy Installations (Jacksonville, FL)
- …arrange invitational travel orders for family members, assisting with travel claims . Consults and collaborates with multidisciplinary teams during initial treatment ... phase and continuing throughout the continuum of care. Ensures that the RSMs, family, and caregivers have access to all medical and non-medical services including rehabilitation, education, employment-related programs, and disability benefits. Initiates… more
- Highmark Health (Tallahassee, FL)
- …5 years with coding languages, analytical software, systems, tools and processes using claims , clinical, enrollment and provider data + 3 years of project leadership ... in a complex, matrixed environment (payer and/or provider preferred) + 3 years of providing analytical consultation to clinical, administrative, operational and financial stakeholders **Preferred** + None **LICENSES or CERTIFICATIONS** **Required** + None… more
- Zelis (St. Petersburg, FL)
- …that shape who you are. Position Overview At Zelis, the Clinical Dispute Analyst role is responsible for the resolution of facility and provider disputes as ... relate to DRG validation, itemized bill review, and/or clinical claim review Expert Claim Review. They will...will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence… more
- NextEra Energy (North Palm Beach, FL)
- …subsidiary and provides coverage to both affiliated and non-affiliated risks. As the Operations Analyst for Claims & Finance, you will be assisting the Claims ... Notice of Loss), following up with TPAs (Third Party Administrators), manage claims BDXs (Bordereau), processing invoices, generate loss runs & reports, documenting… more
- Molina Healthcare (FL)
- …and executing operational initiatives tied to Payment Integrity (PI) and provider claims accuracy. The individual will be relied upon to make independent, informed ... coordination, and ownership of high-value deliverables-distinct from a pure data analyst role. **Job Duties** **Business Leadership & Operational Ownership** +… more
- Molina Healthcare (St. Petersburg, FL)
- …and financial outcomes for all PI solutions. + Leads efforts to improve claim payment accuracy, claim referrals, adjustment analysis and financial performance ... a business lens to ensure accurate interpretation of provider claims trends, payment integrity issues, and process gaps. +...At least 7 years of experience as a Business Analyst or Program Manager in a Managed Care Organization… more
- Acosta Group (Jacksonville, FL)
- …high-severity Workers' Compensation and liability claims . Supervise the Sr. Risk Claims Analyst and ensure alignment with best practices. + Vendor and ... The Director will manage a team including the Sr. Risk Claims Analysts and collaborate closely with internal stakeholders, third-party administrators, brokers,… more