- Zelis (TX)
- …Overview We are seeking a detail-oriented and technically skilled analyst to support healthcare claims repricing and data validation efforts. In this role, you ... insights. Success in this role requires deep familiarity with healthcare claims data, strong SQL proficiency, and...SQL queries (joins, CTEs, subqueries) to extract, manipulate, and audit claim data. + Evaluate pricing scenarios based on… more
- Molina Healthcare (Houston, TX)
- **JOB DESCRIPTION** **Job Summary** Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage ... amount and benefit interpretation. Monitors and controls backlog and workflow of claims \. Oversees analysis of complex claim inquiries and reimbursement issues using… more
- Elevance Health (Houston, TX)
- **External Audit Facilitator** **Location:** This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while ... a dynamic and adaptable workplace. Alternate locations may be considered. The **External Audit Facilitator** is responsible for managing the process for claims … more
- Providence (TX)
- …we must empower them.** **Providence St Joseph Health operates a self-administered claims program for General and Healthcare Professional Liability, Directors ... organizational metrics, and propose opportunity solutions and success replication. Propose monthly audit focus topics to claims leaders based on trending… more
- Houston Methodist (Houston, TX)
- …and capture potential revenue opportunities. This position performs quality assurance, detailed claims analysis and medical record reviews of complex claims and ... FUNCTIONS** + Conducts risk-based and baseline reviews of complex and escalated claims or records in a timely manner, evaluates corrective actions and processes… more
- Conduent (Dallas, TX)
- … Auditor CPhT** **Do you have a CPhT certification?** **Would you like to audit pharmacy claims for accuracy?** **About the Role** Conduent Payment Integrity ... performs in depth pharmacy audits on behalf of our healthcare payer clients. As a Pharmacy Claims ...and pharmacy practices. + Responding to pharmacy calls regarding audit results and dealing with clients periodically to report… more
- HCA Healthcare (Austin, TX)
- …+ Ensuring compliance with federal, state and HCA regulations, policies, procedures, and audit requirements in the use of patient data for research purposes + ... new analytical capabilities. + Constructing and manipulating large electronic claims datasets, knowledge in domain modeling, relational database design, programming… more
- Molina Healthcare (TX)
- …for accurate and timely maintenance of critical provider information on all claims and provider databases. Maintains critical provider information on all claims ... timely manner to meet department standards of turnaround time and quality. + Audit loaded provider records for quality and financial accuracy and provide documented… more
- Elevance Health (Houston, TX)
- …Group (DRG) methodology, including case rate and per diem, generating highly complex audit findings recoverable claims for the benefit of the Company, for ... appeals may only be reviewed by other DRG Coding Audit Principals (or Executives). **How you will make an...you will make an impact:** + Analyzes and audits claims by integrating advanced or convoluted medical chart coding… more
- Molina Healthcare (TX)
- …of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of ... the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as… more
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