- Molina Healthcare (Cleveland, OH)
- …of pharmacy prior authorization requests and/or appeals. * Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other ... necessary information to providers, members and pharmacies. * Assists with clerical tasks and other day-to-day pharmacy call center operations as delegated. * Effectively communicates plan benefit information, including but not limited to: formulary… more
- JPMorgan Chase (Columbus, OH)
- …external events, including catering and transportation + Process invoices and T&E expense claims for team members, ensuring all policies are followed and items are ... processed within provided guidelines + Assist with staff on-boarding and off-boarding, which includes requesting equipment setup and system access + Produce high quality emails and messages to individuals at all levels of the organization + Maintain department… more
- Elevance Health (Columbus, OH)
- …and models data including risk reporting and forecasting. + Calculates monthly claims liability reserves, develops merit rating factors and prepares Department of ... Insurance annual statement exhibits. **Minimum Requirements:** Requires a BA/BS degree and to have passed a minimum of three Society of Actuaries (SOA) or Casualty Actuarial Society (CAS) actuarial exams and a minimum of 1 year related experience; or any… more
- Robert Half Finance & Accounting (Massillon, OH)
- …jurisdictions. * Maintain corporate insurance documentation and coordinate renewals and claims with brokers. * Assist in month-end and year-end close processes ... by preparing schedules and financial statements. * Compile necessary documentation for external tax filings across multiple entities. * Collaborate with auditors and provide required documentation for both internal and external audits. Requirements *… more
- Molina Healthcare (Cincinnati, OH)
- …experience. + Managed Care experience - **_specifically within Payment Integrity, Claims Payment, Provider Relations Experience_** + Experience working in a cross ... functional highly matrixed organization. **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION** : + PMP, Six Sigma Green Belt, Six Sigma Black Belt Certification and/or comparable coursework desired. To all current Molina employees: If you are interested in… more
- Molina Healthcare (Akron, OH)
- …& ABILITIES** : * 2 - 3 years customer service, provider service, or claims experience in a managed care setting. * Working familiarity with various managed ... healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to, fee-for service, capitation and various forms of risk, ASO, etc. **PREFERRED EDUCATION** : Bachelor's Degree in a related… more
- Humana (Columbus, OH)
- …They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business ... at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in complex Medicare reimbursement methodologies. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Process and Network… more
- Molina Healthcare (Akron, OH)
- …+ Develop custom health plan reports related to managed care data like Medical Claims , Pharmacy, Lab and HEDIS rates + Assists and collaborates with the national ... Risk and Quality department with testing of pre-production reporting for the assigned health plan + Calculate and track gap closure and intervention outcome reporting for the assigned state + Work in an agile business environment to derive meaningful… more
- Molina Healthcare (Columbus, OH)
- …supervised learning and rule-based logic to detect potentially incorrectly paid claims . + Contribute to improve data quality, perform data audits, identify ... discrepancies and resolve issues. + Support the identification of opportunities for operational improvement or growth based on analytical findings. + Areas of exposure may include: + Economics/Finance + Data Analysis / Science + Fraud, Waste, and Abuse… more
- Molina Healthcare (Dayton, OH)
- …focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. ... + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the… more
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