• Recovery & Resolution Analyst

    Prime Therapeutics (Columbus, OH)
    …combined pharmacy and PBM experience to include:##1 year of work experience in claims processing in an operations, audit or quality assurance environment##1 year ... for recoupment of audits and investigations performed by the Pharmacy Audit Operations and Special Investigations Unit (SIU) teams. **Responsibilities** + Perform… more
    Prime Therapeutics (04/18/25)
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  • Diagnosis Related Group Clinical Validation…

    Elevance Health (Mason, OH)
    …and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims . **How you will make an impact:** + Analyzes and audits claims ... coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. + Draws on advanced ICD-10 coding expertise, mastery of… more
    Elevance Health (06/04/25)
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  • Investigations Coordinator

    Highmark Health (Columbus, OH)
    …responsible for assisting in the processing and investigation of non-complex health care claims to determine the legitimacy of claim charges. The incumbent will also ... services and charges; will monitor internal referrals from sources such as claims , customer service, Medicare C&D Compliance, and Fraud Hotlines; will alert… more
    Highmark Health (06/03/25)
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  • Remote Accommodations Clinical Specialist-…

    Sedgwick (Columbus, OH)
    …United States. **PRIMARY PURPOSE** : Performs standard clinical evaluations on claims that require additional review based on medical condition, client requirement, ... FUNCTIONS and RESPONSIBILITIES** + Consults on and evaluates complex claims to determine objective, quantifiable, medically supported work restrictions/accommodations.… more
    Sedgwick (05/23/25)
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  • Pharmacy/Clinical Service Data Analyst

    Trinity Health (Columbus, OH)
    …of professional roles including information technology, financial analysis, audit , provider relations and more. **Position Purpose:** Pharmacy/Clinical Service ... Develop and run detailed ad hoc reports for pharmacy claims analysis and review. . Coordinate and work with...with PBM and internal departments related to the pharmacy audit requests. . Trend and identify inappropriate pharmacy utilization… more
    Trinity Health (06/03/25)
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  • Disability Clinical Specialist

    Sedgwick (Dayton, OH)
    …work. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Performs clinical review of referred claims ; documents decision rationale; and completes medical review of all ... claims to ensure information substantiates disability. + Provides clear...status, progress and work status. + Achieves appropriate quality audit scores on a consistent basis. + Acts as… more
    Sedgwick (06/03/25)
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  • OSS Coordinator

    Sedgwick (Columbus, OH)
    …& Insurance OSS Coordinator **PRIMARY PURPOSE** : To support and maintain the claims management system for a local office or multiple office locations; and to ... claim adjustments, provider requests and operational expense check requests. + Queues claims for Managed Care; transfers payment allocations; and runs manual pre-pay… more
    Sedgwick (04/04/25)
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  • Coding Auditor Educator

    Highmark Health (Columbus, OH)
    …OVERVIEW:** Performs all related internal, concurrent, prospective and retrospective coding audit activities. Reviews medical records to determine data quality and ... identified in the audits compliant with regulatory requirements. Provides written audit guidance. Participates with management in the assessment of external … more
    Highmark Health (05/09/25)
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  • Manager, Consulting - Legal Bililing Operations

    Wolters Kluwer (Columbus, OH)
    …platforms. In addition, during heavy periods of incoming invoice volume, conduct the initial audit and/or quality assurance invoice review audit up to 15% of the ... prior supervisory experience, preferably in a legal billing or claims environment. + 5+ years' experience in the legal...and to exercise discretion and sound judgment when making audit and adjustment decisions. + Understanding of legal terminology… more
    Wolters Kluwer (05/14/25)
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  • Investigator

    Highmark Health (Columbus, OH)
    …for proactive and investigative purposes to comply with internal audit and regulatory requirements. **ESSENTIAL RESPONSIBILITIES** + Performs investigations into ... Credentialing or Medical Review Committee. + Engages in delivery of audit results and overpayment negotiations.Responsible for recovery/ savings of misappropriated… more
    Highmark Health (05/08/25)
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