- The County of Los Angeles (Los Angeles, CA)
- …department billing sections and agencies being billed to resolve discrepancies in processing claims . Develops, reviews and analyzes reports to ensure that claims ... Carries out departmental personnel policies and procedures and conducts internal audit reviews to ensure compliance with established policies and procedures.… more
- Robert Half Technology (Martinez, CA)
- …Collaborate with diverse groups including IT, Quality, Medical Directors, Claims & Processing, and Utilization Management. Support governance activities with ... Focus Areas Regulatory Compliance: Map and standardize workflows, strengthen internal audit tools, and prepare the organization for state and federal oversight.… more
- Stanford University (Stanford, CA)
- …established criteria and communicate discrepancies in real time. + Process/assist with claims for dental care and durable medical equipment (DME)/orthopedic brace. + ... NCAA and/or outside secondary insurance for any student-athlete related health insurance claims . + Work collaboratively with the sports medicine clinic (SMC) to help… more
- Humana (Sacramento, CA)
- …records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Decisions are typically related to resources, approach, and ... 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
- City and County of San Francisco (San Francisco, CA)
- …to the general duties above: + Detects, investigates, and prevents fraudulent claims for public assistance to avoid welfare fraud and other financial crimes. ... production of training, policy, and internal business process materials and/or review audit findings as a County or Department representative. + Participates in… more
- Stanford University (Stanford, CA)
- …cost and performance, and ensure accurate and timely plan administration, claims payment, manage escalated issues, etc. + Manage monthly billings, enrollments, ... management; coordinate data gathering for audits; oversight of benefit plan claims , funding, and premium payments. Assist in preparing financial information for… more
- Centene Corporation (Sacramento, CA)
- …fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare ... mining and analysis to detect aberrancies and outliers in claims + Develop new queries and reports to detect...experience. 1+ years of medical claim investigation, medical claim audit , medical claim analysis, or fraud investigation experience. Pay… more
- ICW Group (San Diego, CA)
- …optimizing data models that support actuarial analysis, policy processing, claims processing, underwriting, compliance reporting, and overall business intelligence ... logical, and physical) tailored for Workers Compensation Insurance data such as claims , policies, premiums, exposures, and provider networks. + Builds and maintains… more
- Ankura (Los Angeles, CA)
- …least five (5) recent years of experience in HCC/Risk Adjustment and/or RADV Audit Methodology + Associate's or Bachelor's degree preferred, but not required + ... processes, anatomy and pharmacology. + Intermediate to advanced understanding of in claims processing procedures, state and federal regulations, and Medicare Part D… more
- Walgreens (Santa Monica, CA)
- …Quality Improvement Program. + Ensures the accurate processing of insurance claims to resolve customer issues and prevent payment rejections. Follows-up with ... companies as well as medical providers and conducts or participates in 3rd party audit . + Assists and supports Store Manager and Pharmacy Manager in analyzing and… more