- University of Rochester (Rochester, NY)
- …methodology, including add-ons - - Follow up with payers on incorrectly paid claims through final resolution and adjudication , including refund of credits - ... independent decisions as to the processes necessary to collect denied insurance claims and resolve billing issues. Must track payer/billing issues that affect… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …policies/providers, documentation and communication with Insured, Insured's family, care providers, and adjudication of the claims . All work is directed under ... of services as is deemed necessary. + Evaluates submitted claims to determine if services billed and provided are...file and claim payment to encourage timely submission of claims . Responsible for ensuring that all claims … more
- MetLife (New York, NY)
- … Claims automation: Given the exponential growth of the Pet business, claims cost management is essential. Enhance auto- adjudication models to substantially ... OCR, NLP and LLMs, and building a brand-new ontology for animal health claims . * Governance and data expertise: Establish governance frameworks for data modeling,… more
- Mount Sinai Health System (New York, NY)
- …to Directors for potential legal intervention, and assisting in the escalation of claims that may require involvement from insurance carriers or legal entities. The ... cycle management, with a strong understanding of both hospital and professional claims processes. ? Previous experience in a role that involved analyzing contracts,… more
- University of Rochester (Rochester, NY)
- …independent decisions as to the processes necessary to collect denied insurance claims , no response accounts, and will investigate resolving billing issues. Maintain ... limited to: telephone, photocopy machine, adding machine, personal computer (for claims inquiry and entry software) fax/scanner, Microsoft Word, Excel, Access,… more
- The Institute for Family Health (New Paltz, NY)
- …product lines/plans and issues related to the EPIC system build. + Ensures Retro Adjudication Work Queues are worked weekly to ensure that all affected dates of ... medical professionals and patients' on daily basis to resolve claims processing issues. + Recognize issues relating to provider...Printing/Reviewing of printed claim forms for accuracy to ensure claims are paid timely. + May be responsible for… more
- CVS Health (Albany, NY)
- …Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims ; adjudicates complex, sensitive, and/or specialized claims in accordance ... amount level on customer service platforms by using technical and claims processing expertise. + Applies medical necessity guidelines, determine coverage, complete… more
- Highmark Health (Albany, NY)
- …medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, clearly defines the medical necessity of non-formulary and prior ... Enter all authorizations into the Argus IPNS information system to allow claim adjudication . + Complete other assigned duties as specified. + Identify and report… more
- Humana (Albany, NY)
- …enforcement authorities. Assembles evidence and documentation to support successful adjudication , where appropriate. Conducts on-site audits of provider records ... Bachelor's Degree + Minimum of 3 yrs health insurance claims or Medicare experience + Minimum 3 years of...CPC, CCS, CFE, AHFI) + Understanding of healthcare industry, claims processing and internal investigative process development + Experience… more
- Hannaford (Glenville, NY)
- …claim forms. * Maintain organized filing system for invoices, manual insurance claims , daily reports, etc. in accordance with Standard Practice Manual and state ... in maintenance of third party prescription information and resolution of rejected adjudication . * Initiate prescription renewal requests to doctor via telephone call… more