Reviewer jobs at Centene - 10 jobs

Group Benefit Solutions delivers comprehensive insurance and absence management solutions for mid-sized and large companies. Our work fosters a healthier, happier, and more secure workforce, contributing to New York Life's legacy of being there when we're needed most. Here, you'll design, implement, and support these solutions directly impacting employees' lives. At our core, we provide financial security and peace of mind to people through our absence, accident, disability, voluntary benefits, and life insurance solutions. Click here to learn more about Group Benefits solutions. This position will be based in Pittsburgh, Dallas, Bethlehem or New York with a hybrid work schedule of three days per week in the office. Role Overview: * Complete quality reviews of internal documentation and systems to determine accuracy of deliverables (e.g. claim or calls). * Provide guidance and coaching because of quality review findings. * Professional support role, responsible for specific administrative and/or quality review questions and requests from internal business stakeholder. * Individuals work under limited supervision. What You'll Do: * Quality review deliverables - e.g. such as claim review (Compliance, business or performance guarantee reviews) or coaching - based on job aids, contracts and other SOPs. * Reviews the accuracy of case processing activities such as: claim payments to ensure compliance and consistency with administrative procedures and guidelines. * Executes on appropriate quality methodology by providing consultative services and guidance including quality review methodology, compliance and legal guidelines and business standard references. * Researches, interprets and responds to inquiries from internal customers or partners (Sales, Account Management or Ops management) regarding product and case-specific issues; such as claim investigation and rebuttals. * Identifies and communicates review findings that needs to be escalated appropriately. * Acts as a figure of authority / SME in regard to product knowledge, processes and compliance and legal framework. * Participates in calibration sessions internally and with business partners including vendors. * Handles rebuttal requests. * Manage and/or recommend coaching sessions to address defect and error trends. * Demonstrates seasoned knowledge of Group Insurance products and processes. * Champions GBS Quality Review Program to peers and internal customers. What You'll Bring: * 3+ Group Insured/STD/Absence product experience required * 5+ years of relevant related work experience preferred * Experience in quality control / review preferred * Ability to understand compliance, legal and complex business processes * Coaching skills and experience * Outstanding verbal and written communication * Forward thinking mindset * Attention to details, organized, quality and productivity driven * High School Diploma preferred It is recommended that all qualified candidates apply to this posting as soon as possible. Residents of Colorado are hereby notified that the deadline to apply is two weeks from the Posting Date listed above. #LI-ML1 #LI-HYBRID Pay Transparency Salary range: $57,000-$81,500 Overtime eligible: Nonexempt Discretionary bonus eligible: Yes Sales bonus eligible: No Actual base salary will be determined based on several factors but not limited to individual's experience, skills, qualifications, and job location. Additionally, employees are eligible for an annual discretionary bonus. In addition to base salary, employees may also be eligible to participate in an incentive program. Actual base salary within that range will be determined by several components including but not limited to the individual's experience, skills, qualifications, and job location. In addition to base salary, employees may also be eligible to participate in an incentive program. Our Benefits We provide a full package of benefits for employees - and have unique offerings for a modern workforce, including leave programs, adoption assistance, and student loan repayment programs. Based on feedback from our employees, we continue to refine and add benefits to our offering, so that you can flourish both inside and outside of work. Click here to discover more about our comprehensive benefit options or visit our NYL Benefits Site. Our Diversity Promise We believe in a diverse workforce because it is our mission to advocate for the financial security and success of people in every community. This is why diversity, equity, and inclusion (DEI) are guiding principles that are embedded in our brand and our culture. Click here to learn more about how we have been recognized for our leadership. Recognized as one of Fortune's World's Most Admired Companies, New York Life is committed to improving local communities through a culture of employee giving and volunteerism, supported by the Foundation. We're proud that due to our mutuality, we operate in the best interests of our policy owners. To learn more about career opportunities at New York Life, please visit the Careers page of ******************** Job Requisition ID: 93085 #GBS

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start **Caring. Connecting. Growing together.** The **Itemized Bill Review (IBR) Clinical Appeals Reviewer ** will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self-motivated, solution-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines. This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Analyze scope and resolution of IBR Appeals + Respond to Level one, two or higher appeals + Perform complex conceptual analyses + Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed + Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions + Researches and prepares written appeals + Exercises clinical and/or coding judgment and experience + Collaborates with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims + Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel + Serve as a key resource on complex and / or critical issues and help develop innovative solutions + Define and document / communicate business requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Undergraduate nursing degree + Unrestricted RN (registered nurse) license + 2+ years of appeals experience (coding or auditing) + Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use + Advanced experience with regulations, compliance and composing professional appeal responses + Advanced experience with ICD10 CM coding and ICD 10 PCS coding + Willing or ability to work our normal business hours of 8:00am - 5:00pm + Proven ability to keep all company sensitive documents secure (if applicable) + Have a dedicated work area established that is separated from other living areas and provides information privacy + Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service **Preferred Qualifications:** + Clinical claim review experience + Managed care experience + Investigation and/or auditing experience + Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry + Knowledge of health insurance business, industry terminology, and regulatory guidelines *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $35.00 to $62.50 per hour based on full-time employment. We comply with all minimum wage laws as applicable. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

Blitz Interview Day Walk ins are welcome Thursday 1/22 from 9AM - 12PM & 2PM - 5PM Opportunities Available: Full time Patient Access Rep II - Variety of Shifts/Schedules available Openings at these locations: CHI Memorial Hospital (Chattanooga, TN) Memorial North Park (Hixson, TN) Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: ***************************** The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. **********

**Role Overview:** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full intent of the appeal. **Responsibilities:** + Process appeals, ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors + Outreach to appellants or their representatives to obtain and review medical records + Package pertinent information into a case for determination + Interact with providers to obtain additional clinical information + Engage with members or their advocates to understand the full intent of the appeal + Provide clinical expertise and determine medical necessity for case classifications when necessary + Perform front-line regulatory/compliance functions in the evaluation of appeals + Review appeal cases and ensure the Medical Director makes timely decisions + Review final determinations and create decision letters containing required information as regulatory entities dictate + Present cases to committees when necessary + Utilize InterQual criteria and apply them to appeals reviews + Stay current with the department and AmeriHealth Caritas policies and procedures + Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations **Education & Experience:** + Associate's degree in nursing (ASN) required + 3 or more years of experience in a related clinical setting and working with diagnosis procedure codes + Working knowledge of InterQual criteria + Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook + Familiarity with the appeals process, preferably within a managed care organization **Licensure:** + Current and unrestricted Registered Nurse (RN) licensure or compact state licensure **Skills & Abilities:** + Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes. Your career starts now. We're looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at *************************** **Our Comprehensive Benefits Package** Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

About the role The VA Claims Consultant is responsible for reviewing and addressing technical, medical and viability issues on claimant cases pending at all levels of the Veteran Affairs process. Primary duties include reviewing VA claims file and medical evidence, resolving complex claim issues, and sharing knowledge with claims agents. Instructs, mentors, and trains peers and support staff. Performs work with minimal supervision. What you'll do Review and prepare a summary of the veteran's claims file which includes past and present VA decisions, analyzes medical evidence, reviews VA law and regulations, and determines any error of law administered by the Regional Office and/or Veteran Law Judge in order to compose the brief. Reviews medical records, applications on file, and the claim's agent medical development profile in order to determine which medical records to solicit from the claimant's medical providers. Selects appropriate disability benefit questionnaires and sends to the appropriate provider based upon the claimant's medical conditions. Assist claimants with drafting lay statements; drafting independent medical opinion request letters and case summaries for medical consultants; identifying and sending correct VA disability benefit questionnaires Reviews briefs written by claims agent providing proofreading and research as needed. Reviews cases for technical problems and medical eligibility. Research and identify reference material to support case development and documentation. Processes work in a timely and accurate manner. Accurately and thoroughly document system notes of all conversations and actions. Maintains technical knowledge of all VA programs and procedures. Reviews claims for viability and closure. Contacts claimant/clients to review and discuss. Participates in training sessions and demonstrations. Maintains strict confidentiality of claimant information, procedural manuals, client/prospect lists, information on new business ventures, and other confidential Allsup information. Mentor peers and support staff. Assist, on an as needed basis, with claims agent job functions. Including, but not limited to, claim status, drafting appeals, VA Forms, etc. Work on special projects Qualifications Requires Bachelor's degree or equivalent experience. Must have strong oral and written communication skills and the ability to learn and apply technical instructions. Minimum of two years of Veteran's disability claims handling responsibilities and experience Professional oral/telephone communication skills. Superior organizational skills. High level of initiative. Excellent knowledge of Word and Excel. Benefits Health, Dental, and Vision Insurance 401(K) Matching Short-Term and Long-Term Disability Insurance Life Insurance Paid Time Off Paid Holidays Flexible Spending and Health Savings Account Tuition Reimbursement Pet Insurance Employee Assistance Program DISCLAIMER Tasks, duties, and responsibilities as listed in the job description are not exhaustive. The company may assign other tasks, duties and responsibilities with no prior notice. Equal Opportunity Employer. ALL characteristics protected by federal, state, or local law.

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. The Itemized Bill Review (IBR) Clinical Appeals Reviewer will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self-motivated, solution-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines. This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Analyze scope and resolution of IBR Appeals * Respond to Level one, two or higher appeals * Perform complex conceptual analyses * Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed * Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions * Researches and prepares written appeals * Exercises clinical and/or coding judgment and experience * Collaborates with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims * Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel * Serve as a key resource on complex and / or critical issues and help develop innovative solutions * Define and document / communicate business requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Undergraduate nursing degree * Unrestricted RN (registered nurse) license * 2+ years of appeals experience (coding or auditing) * Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use * Advanced experience with regulations, compliance and composing professional appeal responses * Advanced experience with ICD10 CM coding and ICD 10 PCS coding * Willing or ability to work our normal business hours of 8:00am - 5:00pm * Proven ability to keep all company sensitive documents secure (if applicable) * Have a dedicated work area established that is separated from other living areas and provides information privacy * Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Preferred Qualifications: * Clinical claim review experience * Managed care experience * Investigation and/or auditing experience * Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry * Knowledge of health insurance business, industry terminology, and regulatory guidelines * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $35.00 to $62.50 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Lead the Way in Water Mitigation - Join Our Atlanta Team! Water Mitigation Reviewer ️ What We're Looking For: 2 to 3+ years of related experience ️ Strong negotiation and communication skills Ability to review estimates, control costs, and mentor adjusters Comfortable interacting with contractors, public adjusters, insurers, and attorneys Bachelor's degree Preferred or a minimum of two years experience in the construction water mitigation industry 2 years experience in the restoration or water mitigation construction industry Advanced computer skills including proficiency in Xactimate and XactAnalysis Good time management abilities Strong Analytical and problem solving ability Excellent written, verbal, and oral communication skills Good interpersonal skills IICRC Certification WRT/ASD Certification CDS (Commercial Drying Specialist) AMRT (Applied Microbial Remediation Technician) #LI-JC3 Reviews water mitigation estimates to ensure that they are technically correct and meet industry standards Resolves water mitigation property losses by investigating damages, reviewing estimates and negotiating adjustments of losses Provides mentoring and assists other staff with losses Make sales calls to solicit new business Acquire and develop client relationships that result in new business

Lead the Way in Water Mitigation - Join Our Atlanta Team! Water Mitigation Reviewer ️ What We're Looking For: 2 to 3+ years of related experience ️ Strong negotiation and communication skills Ability to review estimates, control costs, and mentor adjusters Comfortable interacting with contractors, public adjusters, insurers, and attorneys

Lead the Way in Water Mitigation - Join Our Atlanta Team! 💧🌟 Water Mitigation Reviewer 🛠️ What We're Looking For: 📝 2 to 3+ years of related experience 🗣️ Strong negotiation and communication skills 📊 Ability to review estimates, control costs, and mentor adjusters 🤝 Comfortable interacting with contractors, public adjusters, insurers, and attorneys Bachelor's degree Preferred or a minimum of two years experience in the construction water mitigation industry 2 years experience in the restoration or water mitigation construction industry Advanced computer skills including proficiency in Xactimate and XactAnalysis Good time management abilities Strong Analytical and problem solving ability Excellent written, verbal, and oral communication skills Good interpersonal skills IICRC Certification WRT/ASD Certification CDS (Commercial Drying Specialist) AMRT (Applied Microbial Remediation Technician) #LI-JC3 Reviews water mitigation estimates to ensure that they are technically correct and meet industry standards Resolves water mitigation property losses by investigating damages, reviewing estimates and negotiating adjustments of losses Provides mentoring and assists other staff with losses Make sales calls to solicit new business Acquire and develop client relationships that result in new business