- 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
- Molina Healthcare (FL)
- …+ SQL expertise + Excel expertise + Medicare, Medicaid, Marketplace claims expertise **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting ... and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made… 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
- Kemper (Doral, FL)
- …of the NICB Basic and/or Analytics Academies are desirable. + Certified Insurance Fraud Analyst (CIFA), Fraud Claims Law Specialist (FCLS) or Fraud Claims ... College Degree or equivalent work experience * Three years of insurance claims experience or related fraud analytics background. **Position Requirements:** + Strong… 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)
- …Analysis** + Uses a business lens to ensure accurate interpretation of provider claims trends, payment integrity issues, and process gaps. + Applies understanding of ... healthcare regulations, managed care claims workflows, and provider reimbursement models to shape recommendations...At least 7 years of experience as a Business Analyst or Program Manager in a Managed Care Organization… 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 ... Claim Review. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and… more