- Molina Healthcare (Macon, GA)
- …+ 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
- CVS Health (Atlanta, GA)
- …abuse. + Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants and customers. + Researches and ... prepares cases for clinical and legal review. + Documents all appropriate case activity in case tracking system. + Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law. + Facilitates the recovery… more
- Molina Healthcare (Atlanta, GA)
- **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
- CVS Health (Atlanta, GA)
- …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
- WTW (Atlanta, GA)
- …management program design, pharmacy solutions, disability/absence management strategies and claims audit services. Product-based solutions such as our pharmacy ... purchasing coalition round out our broad-based suite of offerings. **Explore an opportunity:** WTW's Recent College Graduate Program (RCGP) is a centrally run, 12-month program for recent college graduates. The program offers a centralized team to support… more
- Highmark Health (Atlanta, GA)
- …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
- BrightSpring Health Services (Valdosta, GA)
- …related in health care administrative, financial, or insurance customer services, claims , billing, call center or management regardless of industry. + Proficient ... computer skills and knowledge of Microsoft Office ADD and above average Excel skills. + Proficient 10 key skills. + Possess the technical aptitude required to understand flow of data through systems as well as system interactions. + HCHB (Home Care Home Base)… more
- Molina Healthcare (Augusta, GA)
- …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
- Elevance Health (Atlanta, GA)
- …content strategy to meet financial and operational targets. As a Clinical Content Analyst , you'll research and interpret CMS, CPT/AMA and other major payer policies ... and finally data validation. Your goal is to develop claims editing logic and content that promote payment accuracy...Scaled Agile Framework Training preferred. + 5+ years of claims editing experience with healthcare payers and/or claims… more
- The Hartford (Alpharetta, GA)
- …a seasoned technology leader to oversee the development and maintenance of our Claims application ecosystem. This role is pivotal in driving the modernization and ... operational excellence of our Claims systems, which are built on a modern tech...lead a team of Tech Leads, Senior Developers, Business Analyst , and Scrum Master, and will be responsible for… more