Claims Analyst jobs at Zelis - 416 jobs

The Claims Analyst is responsible for analyzing, appealing, and resolving denied or underpaid medical insurance claims to ensure accurate reimbursement for healthcare services. This role requires a deep understanding of payer requirements, billing codes, and denial management processes to identify root causes and prevent future denials. JOB DUTIES: Review and research denied or underpaid claims from insurance carriers, identifying denial trends and root causes. Prepare and submit timely and accurate appeals with supporting medical documentation and payer guidelines. Communicate effectively with insurance companies to follow up on outstanding denials and appeal status. Collaborate with billing, coding, and client account teams to resolve discrepancies and ensure claim accuracy. Update claim activity notes in the system and maintain detailed documentation of actions taken. Identify patterns or systemic issues contributing to denials and report findings to leadership for process improvement. Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, etc.). Meet or exceed productivity and quality standards established by the RCM department. Participate in ongoing training to stay updated on payer policies, billing regulations, and denial trends. Review and research denied or underpaid claims from insurance carriers, identifying denial trends and root causes. Prepare and submit timely and accurate appeals with supporting medical documentation and payer guidelines. Communicate effectively with insurance companies to follow up on outstanding denials and appeal status. Collaborate with billing, coding, and client account teams to resolve discrepancies and ensure claim accuracy. Update claim activity notes in the system and maintain detailed documentation of actions taken. Identify patterns or systemic issues contributing to denials and report findings to leadership for process improvement. Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, etc.). Meet or exceed productivity and quality standards established by the RCM department. Participate in ongoing training to stay updated on payer policies, billing regulations, and denial trends. REPORTING RELATIONSHIPS: This position works under general supervision, according to established procedures; decides how and when to complete tasks, and reports major activities through periodic meetings and written reports. This position reports directly to the RCM Manager. JOB REQUIRMENTS: · High school diploma required; bachelor's degree preferred. · Minimum of 3 years of experience working with hospital claim denials. · Strong analytical and problem-solving skills. · Excellent written and verbal communication skills. · Ability to multitask while maintaining strong attention to detail. · Ability to work under pressure and meet tight deadlines. · Intermediate proficiency in Microsoft Office (Excel, Word, Outlook). · Must obtain and maintain the HBIZ Denial Recovery Specialist Certification. Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law. HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Responsible for extracting knowledge and insights from data in order to investigate business/operational problems through a range of data preparation, modeling, analysis, and/or visualization techniques. Essential Functions * Collects, monitors and analyzes Medicare Advantage and D-SNP Claims reporting to ensure timeliness, accuracy and compliance internally to support decisions on day-to-day operations, strategic planning, and/or specific business performance issues. * Reviews, tracks, and communicates key performance indicators (KPIs) related to regulatory compliance, timeliness, and accuracy. * Performs data validation of source-to-target data for data visuals and dashboards. * Creates and updates claim reports. * Collates, models, interprets, and analyzes data. * Identifies trends and explains variances and trends in data, recommends actions, and escalates to leaders as appropriate. * Identifies and documents enhancements to modeling techniques. * Completes thorough quality assurance procedures, ensuring accuracy, reliability, trustworthiness, and validity of work. * Provides audit support, both internal and external, which includes supporting the monthly Claims Compliance Monitoring and Organization Determination, Appeals, and Grievances (ODAG/ODR) reporting processes for all Medicare Advantage and D-SNP contracts. * Works closely with internal departments, including but not limited to Enrollment, Customer Service, Reimbursement Strategy, Benefits, Product, Configuration, IT, and Digital Services to ensure seamless coordination and integration for claims data analysis. * Collaborate with vendor partners to monitor and analyze claims reporting. * Identifies operational inefficiencies or process bottlenecks and recommend improvements to enhance workflows, reduce costs, and improve member and provider satisfaction. * Assist with the implementation and management of new medical health plan products or changes to existing plans. * Support the creation and maintenance of medical health plan policies, procedures, and workflows to ensure compliance with CMS and EOHHS regulatory requirements. * Performs other duties as assigned * Complies with all policies and standards Qualifications Education * Bachelor's Degree required; experience can be substituted for degree Experience * At least 2-3years of medical claims processing and/or data analysis within the health insurance or healthcare industry experience required * Medicare experience required. * Massachusetts Medicaid experience required. Knowledge, Skills, and Abilities * Healthcare knowledge, particularly as it pertains to medical claims processing data, is preferred but not required. * Working knowledge of relational databases, SQL, Power BI, data visualization, and business intelligence tools such as Tableau. * Knowledge and application of statistical analyses, including variance analysis and statistical significance, are preferred. * Project management skills and/or experience are a plus. * Proficiency with Microsoft Office Suite, including Word, Excel and PowerPoint. Additional Job Details (if applicable) Working Conditions * This is a remote role that can be done from most US states * This role is 40 hours/week with five 8-hour days, with a typical schedule of 8:30 am to 5:00 pm Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $62,400.00 - $90,750.40/Annual Grade 6 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Full Time 12238 Silicon Drive Professional Non-Nursing Day Shift $19.80 - $31.25 /RESPONSIBILITIES Analyze complex problems pertaining to claim payments, eligibility, other insurance, transplants and system issues that are beyond the scope of claim examiners and senior claim examiners that affect claims payment. Act as consultant to claims staff in complex claim issue resolution. Work cooperatively with Configuration in testing of contracts used in business operations and reporting to ensure auto adjudication. Perform in accordance with company standards and policies. Promote harmonious relationships within own department, with other departments and within CFHP. Operate under limited supervision. EDUCATION/EXPERIENCE High school diploma or GED equivalent is required. Five years' HMO/PPO claims experience required. Amisys claims processing system experience preferred. Knowledgeable of all benefit programs offered by the CFHP, Medicaid, HMO, PPO, ASO.

Full Time 12238 Silicon Drive Professional Non-Nursing Day Shift $19.80 - $31.25 /RESPONSIBILITIES Analyze complex problems pertaining to claim payments, eligibility, other insurance, transplants and system issues that are beyond the scope of claim examiners and senior claim examiners that affect claims payment. Act as consultant to claims staff in complex claim issue resolution. Work cooperatively with Configuration in testing of contracts used in business operations and reporting to assure auto adjudication. Perform in accordance with company standards and policies. Promote harmonious relationships within own department, with other departments and within CFHP. Operate under limited supervision. EDUCATION/EXPERIENCE High school diploma or GED equivalent is required. Five years HMO/PPO claims experience required. Amisys claims processing system experience preferred. Knowledgeable of all benefit programs offered by the CFHP, Medicaid, HMO, PPO, ASO.

Competitive Compensation & Benefits Package! eligible for - Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer See attachment for additional details. Office Location: Remote Option; Available for any of Partners' NC locations Projected Hiring Range: Depending on Experience Closing Date: Open Until Filled Primary Purpose of Position: This position is responsible for ensuring that providers receive timely and accurate payment. Role and Responsibilities: 50%: Claims Adjudication Responsible for finalizing claims processed for payment and maintaining claims adjudication workflow, reconciliation and quality control measures to meet or exceed prompt payment guidelines. Responsible for reconciling provider claims payments through quality control measures, generally accepted accounting principles and agency's policies and procedures. Assess Title XIX and non-Title XIX claims adjustments for correction or recoupment and will coordinate the recoupment process to ensure payment is recovered for inappropriately paid claims. Provide back up for other Claims Analysts as needed. 40%: Customer Service Maintain provider satisfaction by being available during regular business hours to handle provider inquiries; interacting in a professional manner; providing information and assistance; and answering incoming calls. Assist providers in resolving problem claims and system training issues. Serve as a resource for internal staff to resolve eligibility issues, authorization, overpayments, recoupments or other provider issues related to claims payment. 10%: Compliance and Quality Assurance Review internal bulletins, forms, appropriate manuals and make applicable revisions Review fee schedules to ensure compliance with established procedures and processes. Attend and participate in workshops and training sessions to improve/enhance technical competence. Knowledge, Skills and Abilities: Working knowledge of the Medicaid Waiver requirements, HCPCS, revenue codes, ICD-10, CMS 1500/UB04 coding, compliance and software requirements used to adjudicate claims General knowledge of office procedures and methods Strong organizational skills Excellent oral and written communication skills with the ability to understand oral and written instructions Excellent computer skills including use of Microsoft Office products Ability to handle large volume of work and to manage a desk with multiple priorities Ability to work in a team atmosphere and in cooperation with others and be accountable for results Ability to read printed words and numbers rapidly and accurately Ability to enter routine and repetitive batches of data from a variety of source documents within structured time schedules Ability to manage and uphold integrity and confidentiality of sensitive data Education and Experience Required: High School graduate or equivalent and three (3) years of experience in claims reimbursement in a healthcare setting; or an equivalent combination of education and experience. Education and Experience Preferred: N/A Licensure/Certification Requirements: N/A

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Responsible for extracting knowledge and insights from data in order to investigate business/operational problems through a range of data preparation, modeling, analysis, and/or visualization techniques. Essential Functions -Collects, monitors and analyzes Medicare Advantage and D-SNP Claims reporting to ensure timeliness, accuracy and compliance internally to support decisions on day-to-day operations, strategic planning, and/or specific business performance issues. -Reviews, tracks, and communicates key performance indicators (KPIs) related to regulatory compliance, timeliness, and accuracy. -Performs data validation of source-to-target data for data visuals and dashboards. -Creates and updates claim reports. -Collates, models, interprets, and analyzes data. - Identifies trends and explains variances and trends in data, recommends actions, and escalates to leaders as appropriate. -Identifies and documents enhancements to modeling techniques. -Completes thorough quality assurance procedures, ensuring accuracy, reliability, trustworthiness, and validity of work. -Provides audit support, both internal and external, which includes supporting the monthly Claims Compliance Monitoring and Organization Determination, Appeals, and Grievances (ODAG/ODR) reporting processes for all Medicare Advantage and D-SNP contracts. -Works closely with internal departments, including but not limited to Enrollment, Customer Service, Reimbursement Strategy, Benefits, Product, Configuration, IT, and Digital Services to ensure seamless coordination and integration for claims data analysis. -Collaborate with vendor partners to monitor and analyze claims reporting. -Identifies operational inefficiencies or process bottlenecks and recommend improvements to enhance workflows, reduce costs, and improve member and provider satisfaction. -Assist with the implementation and management of new medical health plan products or changes to existing plans. -Support the creation and maintenance of medical health plan policies, procedures, and workflows to ensure compliance with CMS and EOHHS regulatory requirements. -Performs other duties as assigned -Complies with all policies and standards Qualifications Education Bachelor's Degree required; experience can be substituted for degree Experience At least 2-3years of medical claims processing and/or data analysis within the health insurance or healthcare industry experience required Medicare experience required. Massachusetts Medicaid experience required. Knowledge, Skills, and Abilities Healthcare knowledge, particularly as it pertains to medical claims processing data, is preferred but not required. Working knowledge of relational databases, SQL, Power BI, data visualization, and business intelligence tools such as Tableau. Knowledge and application of statistical analyses, including variance analysis and statistical significance, are preferred. Project management skills and/or experience are a plus. Proficiency with Microsoft Office Suite, including Word, Excel and PowerPoint. Additional Job Details (if applicable) Working Conditions This is a remote role that can be done from most US states This role is 40 hours/week with five 8-hour days, with a typical schedule of 8:30 am to 5:00 pm Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $62,400.00 - $90,750.40/Annual Grade 6 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Park Nicollet is looking to hire a Claims Specialist to join our team! Come join us as a Partner for Good and help us make an impact on the care and experience that our patients and their families receive every day. This position ensures that insurance and other 3rd party claims are submitted and/or paid in a timely manner and are compliant with applicable regulations and payer requirements. Specific assignments may include pre-adjudication and/or follow-up, facility and/or professional claims, commercial and/or government payers. Effective performance of these functions helps the organization achieve strong cash flow and maximize patient satisfaction. Required Qualifications: Knowledge, Skills, and Abilities: Requires strong attention to detail and demonstrated problem resolution skills. Must be able to effectively communicate verbally and via written documents. Moderate personal computer proficiency with word processing, spreadsheets and email is required (preference for Microsoft Suite). Working knowledge of typical office equipment is expected. Preferred Qualifications: Education, Experience or Equivalent Combination: Experience in a health care revenue cycle environment preferred. Knowledge, Skills, and Abilities: Ability to acquire and retain complex knowledge of department/company processes, government policy/regulation, and payer requirements. Prior medical terminology and procedural/diagnostic coding (CPT, ICD) knowledge will be helpful. Proficiency with Health Information Systems (e.g., Epic) preferred. Benefits: Park Nicollet offers a competitive benefits package (for eligible positions) that includes medical insurance, dental insurance, a retirement program, time away from work, insurance options, tuition reimbursement, an employee assistance program, onsite clinic and much more!

**Work Schedule** **This position requires three days per week in office (Tues/Wed/Thurs) at either: 1101 Greenwood Blvd. Lake Mary, FL. or 100 Church St. New York, NY.** **Duties & Responsibilities** : + Conducts independent assessments of current claims edits to ensure comprehensive and defensible claims editing is in place across all Healthfirst product lines. + Proactively identifies areas of opportunity with respect to new edits, modifications to existing edits, and recommended claims policy changes. + Leads implementation efforts with respect to new or modified edits and works with other departments to ensure proper integration with existing systems and edits. + Monitors and reports on performance of current claims editing packages to substantiate savings to Healthfirst. + Serves as a subject matter expert to defend claims payment policy disputes and appeals. + Reviews claims editing escalated provider disputes/appeals and provides guidance on coding rules and industry standards across all areas of the company with regards to claims editing and proper coding, billing, and payment. + Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc. + Collaborates with claims editing vendors to maintain and update edits as changes in the regulatory, legislative, or industry accepted payment policy requires. + Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines. + Leads continuous improvement and quality initiatives to improve processes across departments. + Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider. + Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards. + Navigates CMS and State specific websites, as well as AMA guidelines, and compares to current payment policy configuration to resolve the provider payment discrepancies. + Reviews medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines to determine if a claim adjustment is necessary. + Processes claim adjustment requests following all established adjustment and claim processing guidelines. + Identifies and escalates root cause issues to supervisor for escalated review. + Reviews and responds independently to internally escalated provider disputes transferred by management and other associates. + Additional duties as assigned **Minimum Qualifications:** + Coding certification from either American Academy of Professional Coders (AAPC), Certified ProfessionalCoders (CPC) or American Health Information Management Association (AHIMA). + High school diploma or GED from an accredited institution. **Preferred Qualifications:** + Previous relevant experience + Bachelors degree in related field + Time management, critical/creative thinking, communication, and problem-solving skills + Demonstrated professional writing, electronic documentation, and assessment skills. + Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills. + Knowledge of anatomy and pathophysiology medical terminologies. Compliance & Regulatory Responsibilities: See Above License/Certification: See Above WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Winner of the Best and Brightest Companies to Work for in Boston and in the Nation by the National Association for Business Resources (NABR) for the third consecutive year

Job DescriptionDescription: Under the general direction of the Director of Business Services, the Hospital Claims Analyst will perform accurate/timely filing of initial insurance claims and secondary claims, follow up of claims not paid to assure payment to hospital and/or affiliated entities to maintain adequate cash flow and accounts receivable balance, in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast pace and dynamic environment. Hours: M-F, 8:30am - 5:00pm STANDARDS OF PERFORMANCE Processes and adjust inpatient and outpatient medical claims in a timely fashion according to departmental quality and production standards. Assists Director of Business Services in researching and determining status of medical claims to assure billed dollars, claims aging, and pend values are consistent with contract provisions. Performs follow up and takes necessary actions required to resolve all errors and findings assessed by Internal Audit and performance improvement plans. Ensures the validity of claims by reviewing files and attached documentation for completeness and accuracy. Identifies patterns in resubmitted and adjusted claims. Identifies errors, trends, and inconsistencies that require revisions to claim guidelines or system modifications. Documents systemic root cause analysis and recommend solutions to Director of Business Services. Resolves claims issues received by researching claim situations and provide timely reports and responses. Enhances department productivity by recommending improvements to workflow processes and organizational structure. Ensures the completeness and accuracy of Standard Operating Procedures by providing feedback to the department director on procedures that require documentation or additional detail. Contributes to the team effort by accomplishing the related goals and results as determined by the Insurance and Billing Department leadership team. Maintains documentation to support avoidance to negative financial, regulatory, and operational impact. Researches and responds to inquiries from various departments. Provide detailed reporting on claims volume, billed charges, savings, etc. Increase subrogation recovery efforts on approved claims. Assist in gathering customer feedback, defining processes, and identifying best practices. Handles PHI and maintains member privacy in accordance with HIPAA standards at all levels. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04's, 1500's and contract billing. Review every account on ATB for insurance financial class and review and resolve auto rejected claims. Exception will be Medicaid and Medicare which should be forwarded to Business Services, Medicaid/Medicare primary A/R Analyst. Secondary A/R's should be forwarded to the Business Services, Secondary insurance, primary A/R Analyst. Add insurance information into system and set to bill. Review all credit balance accounts and process patient refunds. Review all accounts on ATB for correct contractual and non-covered services. Review all accounts on ATB to identify master accounts and test accounts. Review all accounts on PP/ATB regarding denials due to lack of patient response. Review all accounts on ATB and identify and write up any adjustments such as employee discount, pp discounts. Etc., and forward for bad debt processing. Assist in answering phone calls and walk-ins. Must participate in continuing education and training to maintain and improve knowledge and skills as related professional skillset and the patient population EHS serves. Ensure proper infection control, OSHA and safety standards. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04's, 1500's and contract billing. Other duties as requested, required, or assigned within scope of job and training. Requirements: Minimum Level of Education: Education level equivalent to completion of high school diploma. Formal Training: claims experience skills including investigation, resolution and operations. Skill and experience in planning, organizing, implementing, facilitating, verbal and written communications. Must possess basic typing skills; have the ability to manage cash and give change; and use proper telephone etiquette. Licensure, Certification, Registration: None required. Formal classes in Medical Office Procedure, and Medical Billing are preferred. Work Experience: Two years billing/collection experience in the healthcare field. Intermediate computer skills with word processing and spreadsheet capabilities. Computer Skills: Intermediate computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel); scheduling appointments/updating calendars

Full-time Description Under the general direction of the Director of Business Services, the Hospital Claims Analyst will perform accurate/timely filing of initial insurance claims and secondary claims, follow up of claims not paid to assure payment to hospital and/or affiliated entities to maintain adequate cash flow and accounts receivable balance, in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast pace and dynamic environment. Hours: M-F, 8:30am - 5:00pm STANDARDS OF PERFORMANCE Processes and adjust inpatient and outpatient medical claims in a timely fashion according to departmental quality and production standards. Assists Director of Business Services in researching and determining status of medical claims to assure billed dollars, claims aging, and pend values are consistent with contract provisions. Performs follow up and takes necessary actions required to resolve all errors and findings assessed by Internal Audit and performance improvement plans. Ensures the validity of claims by reviewing files and attached documentation for completeness and accuracy. Identifies patterns in resubmitted and adjusted claims. Identifies errors, trends, and inconsistencies that require revisions to claim guidelines or system modifications. Documents systemic root cause analysis and recommend solutions to Director of Business Services. Resolves claims issues received by researching claim situations and provide timely reports and responses. Enhances department productivity by recommending improvements to workflow processes and organizational structure. Ensures the completeness and accuracy of Standard Operating Procedures by providing feedback to the department director on procedures that require documentation or additional detail. Contributes to the team effort by accomplishing the related goals and results as determined by the Insurance and Billing Department leadership team. Maintains documentation to support avoidance to negative financial, regulatory, and operational impact. Researches and responds to inquiries from various departments. Provide detailed reporting on claims volume, billed charges, savings, etc. Increase subrogation recovery efforts on approved claims. Assist in gathering customer feedback, defining processes, and identifying best practices. Handles PHI and maintains member privacy in accordance with HIPAA standards at all levels. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04's, 1500's and contract billing. Review every account on ATB for insurance financial class and review and resolve auto rejected claims. Exception will be Medicaid and Medicare which should be forwarded to Business Services, Medicaid/Medicare primary A/R Analyst. Secondary A/R's should be forwarded to the Business Services, Secondary insurance, primary A/R Analyst. Add insurance information into system and set to bill. Review all credit balance accounts and process patient refunds. Review all accounts on ATB for correct contractual and non-covered services. Review all accounts on ATB to identify master accounts and test accounts. Review all accounts on PP/ATB regarding denials due to lack of patient response. Review all accounts on ATB and identify and write up any adjustments such as employee discount, pp discounts. Etc., and forward for bad debt processing. Assist in answering phone calls and walk-ins. Must participate in continuing education and training to maintain and improve knowledge and skills as related professional skillset and the patient population EHS serves. Ensure proper infection control, OSHA and safety standards. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04's, 1500's and contract billing. Other duties as requested, required, or assigned within scope of job and training. Requirements Minimum Level of Education: Education level equivalent to completion of high school diploma. Formal Training: claims experience skills including investigation, resolution and operations. Skill and experience in planning, organizing, implementing, facilitating, verbal and written communications. Must possess basic typing skills; have the ability to manage cash and give change; and use proper telephone etiquette. Licensure, Certification, Registration: None required. Formal classes in Medical Office Procedure, and Medical Billing are preferred. Work Experience: Two years billing/collection experience in the healthcare field. Intermediate computer skills with word processing and spreadsheet capabilities. Computer Skills: Intermediate computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel); scheduling appointments/updating calendars

Full Time 12238 Silicon Drive Clerical Day Shift $18.75 - $24.25 /RESPONSIBILITIES Performs adjudication of medical (HCFA) or hospital (UB92) claims for Medicaid, Commercial, and CHIP (Children's Health Insurance Program) according to departmental and regulatory requirements. Maintains audit standards as defined by the Department. EDUCATION/EXPERIENCE High school diploma or GED equivalent is required. Two or more years of experience in claim processing and/or billing experience required. Specific knowledge and experience in Medicaid, CHIP and commercial claim processing preferred. Knowledge of ICD-9, CPT 4 coding and medical terminology is required.

Full Time 12238 Silicon Drive Clerical Day Shift $18.75 - $24.25 /RESPONSIBILITIES Performs adjudication of medical (HCFA) or hospital (UB92) claims for Medicaid, Commercial, and CHIP (Children's Health Insurance Program) according to departmental and regulatory requirements. Maintains audit standards as defined by the Department. EDUCATION/EXPERIENCE High school diploma or GED equivalent is required. Two or more years of experience claim processing and/or billing experience required. Specific knowledge and experience in Medicaid, CHIP and commercial claim processing preferred. Knowledge of ICD-9, CPT 4 coding and medical terminology is required.

Why work with us? The North American branch of Generali Global Assistance offers a diverse and inclusive work environment while employees work towards making real difference in the lives of our clients. As an Organization, we pride ourselves with offering white glove service while being mindful of corporate responsibility and our environmental footprint. Employees enjoy a plethora of benefits to include: A diverse, inclusive, professional work environment Flexible work schedules Company match on 401(k) Competitive Paid Time Off policy Generous Employer contribution for health, dental and vision insurance Company paid short term and long term disability insurance Paid Maternity and Paternity Leave Tuition reimbursement Company paid life insurance Employee Assistance program Wellness programs Fun employee and company events Discounts on travel insurance Who are we? Generali Global Assistance is proudly part of the Europ Assistance Group brand and our products utilize a number of corporate and product brands. The brands for our North American team include the following: CSA: US travel insurance brand for retail and lodging partners. Learn more here. Generali Global Assistance (GGA): The primary Corporate brand in the United States for our travel insurance, travel assistance, identity and cyber protection, and beneficiary companion products. Learn more here. GMMI: the industry standard for global medical cost containment and medical risk management solutions. Learn more here. Iris, Powered by Generali: identity and digital protection solution. Learn more here. Trip Mate: US travel insurance brand for tour operator, cruise and airline partners. Learn more here. What you ll be doing. Job Summary: This position is responsible for analyzing and processing insurance claims to determine the extent of the insurance carrier s liability in a manner that supports the mission, values, and standards of the Company. Primary responsibilities include efficient adjudication of insurance claims, both phone and written communication with insureds, travel suppliers, medical facilities, and others, as well as maintaining all state Department of Insurance regulations for claims files. Weekends may be required. This position reports to the Claims Supervisor. Claims Processing and Coordination Process all claims assigned in a timely, efficient, and accurate manner ensuring that all appropriate policies, procedures, and standard best practices are being followed. Review information on claim forms, Physician Statements, and other documentation to ascertain completeness and validity of claims. Correspond with insureds, physicians, agents, and other appropriate parties to obtain proper documentation and to finalize claims. Maintain proper reserves on each claim file. Ensure that proper file documentation is collected and maintained, including all records of correspondence and telephone conversations. Investigate claims and direct the activities of outside adjusters and investigators. Issue denial of benefits letters when appropriate. Process attorney represented claims files. Review and respond to Department of Insurance complaint letters. Respond to written and phone inquiries regarding claims status. Issue payments in a timely and accurate manner. Ensure that current Federal and State insurance claims regulations, laws, and best practices are being employed consistently for all jurisdictions. Customer Service Answer questions and respond to inquiries from internal and external customers regarding coverage issues and general policy information. Teamwork and Department Support Assist in the mentoring and training of other employees as directed. Perform other duties or special projects as assigned by the management team. Required / Desired Knowledge, Experiences and Skills: Exceptional communication, problem-solving, and organizational skills. Strong reading, writing, comprehension, and proofreading skills. Knowledge of standard concepts, practices, regulations, and laws within insurance field preferred. Bilingual English/Spanish language fluency verbal, reading, and writing skills, is a plus. Previous claims and customer service experience are highly preferred. Education/Certifications: Requirements: High School Diploma or Equivalent (GED) required. Travel Requirements: None Where you ll be doing it. This is a hybrid role based out of our Pembroke Pines, FL office. As a hybrid role, you will be working onsite 2-3 days a week and working from home 2-3 days a week. When you ll be doing it. While there is some flexibility in the hours, this position will be Monday-Friday during regular business hours (approximately 8:00am-5:00pm). Occasional overtime may be required according to business need. Apply today to begin your next chapter. Don t meet every single requirement? At Generali Global Assistance, we are dedicated to building a diverse, inclusive and enriching workplace, so if you re excited about this role but your past experience doesn t align perfectly with every qualification in the job description, we encourage you to apply anyways. You may be just the right candidate for this or other roles. California Residents - Privacy Notice for California Residents Seeking Employment with Generali Global Assistance is available here: *************************************************************************************************** The Company is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any classification protected under federal, state, or local law is a violation of our policy. Equal employment opportunity is provided to all employees and applicants for employment without regard age, race, color, religion, creed, sex, gender identity, gender expression, transgender status, pregnancy, childbirth, medical conditions related to pregnancy or childbirth, sexual orientation, national origin, ancestry, ethnicity, citizenship, genetic information, marital status, military status, HIV/AIDS status, mental or physical disability, use of a guide or support animal because of blindness, deafness, or physical handicap, or any other legally protected basis under applicable federal, state, or local law. This policy applies to all terms and conditions of employment, including, but not limited to, recruitment and hiring, classification, placement, promotion, termination, reductions in force, recall, transfer, leaves of absences, compensation, and training. Any employees with questions or concerns about equal employment opportunities in the workplace are encouraged to bring these issues to the attention of Human Resources. The Company will not allow any form of retaliation against individuals who raise issues of equal employment opportunity. All Company employees are responsible for complying with the Company s Equal Opportunity Policy. Every employee is to treat all other employees equally and fairly. Violations of this policy may subject an employee to disciplinary action, up to and including termination of employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. * This is a Full time in office position: 19100 Ridgewood Pkwy San Antonio, TX 78259 * Anticipated Training Class Start Date: 2/2 or 3/2 * Schedule Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. * Day-to-day processing of claims for accounts: * Responsible for processing of claims (medical, dental, vision, and mental health claims) * Claims processing and adjudication. * Claims research where applicable. * Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). * Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. * Investigation and overpayment administration: * Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. * Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. * Utilize systems to track complaints and resolutions. * Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: * 2+ years related work experience. * Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. * High school diploma or GED * Knowledge of CPT and ICD-9 coding required. * Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. * Must possess proven judgment, decision-making skills and the ability to analyze. * Ability to learn quickly and multitask. * Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. * Concise written and verbal communication skills required, including the ability to handle conflict. * Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. * Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: * Some college courses in related fields are a plus. * Other experience in processing all types of medical claims helpful. * Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: * Medical, dental, vision, life and global travel health insurance * Income protection benefits: life insurance, Short- and long-term disability programs * Leave programs to support personal circumstances. * Retirement Savings Plan includes employer contribution and employer match * Paid time off, volunteer time off, and 11 holidays * Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Full-time Description The Claims Supervisor manages the operational activities and staff of the Claims Department in accordance with the Company guidelines, client needs, and State and Federal requirements. Duties and Responsibilities • Oversee and manage daily activities and functions of the Claims Examiners processing claims for services that are capitated with the health plan. • Responsible for overseeing the claim department's daily operations, including but not limited to, running daily/frequent reports to ensure claims are processed timely, accurately, and in compliance with all federal and state healthcare plan laws and regulations. • Develop, implement, and update Claims Policies and Procedures to ensure compliance with CMS, Medicaid, HIPPA regulations, and health plan requirements. • Report overpayments, underpayments, and other irregularities. • Manage and close out claims open tickets and provider claims disputes. • Ensure optimal handling of all claims, investigate claims issues, and provide claims training for all business units. • Work together with Provider Servicing and participate in provider education, as necessary. • Maintain a fully comprehensive understanding of the covered benefits, coding, and reimbursement policies and contracts. • Act as Subject Matter Expert in issues related to claims processing, payment dispute resolution, cost containment, audit processes, and contract interpretation. • Actively collaborate with management and staff to ensure that “best practices” are followed and continually seek efficient and innovative processes, technologies, and approaches to optimize the use of resources and enhance operations. • Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments. • Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences. • Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments. • Analyze and adjudicate complex claims when examiner is requesting Supervisor review. • Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures when necessary. • Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter when necessary. • Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing. • Perform pre-payment audit and payment cycle. • Complies with performance standards as set forth by the department head. • Follow company policies, procedures, and guidelines to ensure legal compliance. • Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation. • Update and maintain departmental and specialty network standards of operating procedure (SOP). • Regularly meet with VP of Operations - to discuss and resolve reimbursement issues or billing obstacles. • Performs one on one meeting with the individual staff members. Requirements Knowledge • Bachelor's Degree or equivalent experience • 3-5 years of Claims Management experience in the healthcare organization preferred • 3-5 years of experience where you were responsible for setting standards and goals that met or exceeded company and client Service Level Agreements (SLA's). Skills • Intermediate Excel knowledge required. • Demonstrated experience developing and lading process improvement projects that drove operations efficiencies. • An entrepreneurial mindset geared toward creating, executing, and continuously improving health plan operations and implementations. Salary Description $60,000.00 - $65,000.00 per year

We are seeking a Claims Examiner to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations. About the Role: The Claims Examiner plays a critical role in the health care and social assistance industry by thoroughly reviewing and evaluating insurance claims to ensure accuracy, compliance, and appropriateness of payments. This position involves analyzing medical documentation, policy details, and billing information to determine the validity of claims and identify any discrepancies or potential fraud. The Examiner collaborates with healthcare providers, insurance agents, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the Examiner helps protect the organization from financial loss and supports the delivery of fair and efficient claims processing. Ultimately, this role contributes to the integrity and sustainability of the healthcare insurance system by ensuring claims are processed accurately and ethically. Minimum Qualifications: High school diploma or GED Minimum of 2 years experience in claims examination, medical billing, or healthcare insurance processing. Strong understanding of medical terminology, insurance policies, and healthcare billing codes (e.g., ICD-10, CPT). Proficiency with claims management software and Microsoft Office suite. Preferred Qualifications: Associate's degree or Bachelor's degree in health administration, healthcare management, or a related discipline. Certification such as Certified Professional Coder (CPC) or Certified Claims Professional (CCP). Experience working within the health care and social assistance industry or with government healthcare programs. Familiarity with regulatory frameworks such as HIPAA and the Affordable Care Act. Responsibilities: Review and analyze health insurance claims for completeness, accuracy, and compliance with policy terms and regulatory requirements. Verify medical codes, treatment documentation, and billing information to ensure services are properly covered and billed. Investigate and resolve claim discrepancies by communicating with providers, members, and internal departments. Identify and escalate potential fraudulent claims or billing errors to compliance or legal teams. Maintain detailed records of claim evaluations and stay current with healthcare laws and industry standards to support audits and improve processing workflows.

Job Description We are seeking a Claims Examiner to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations. About the Role: The Claims Examiner plays a critical role in the health care and social assistance industry by thoroughly reviewing and evaluating insurance claims to ensure accuracy, compliance, and appropriateness of payments. This position involves analyzing medical documentation, policy details, and billing information to determine the validity of claims and identify any discrepancies or potential fraud. The Examiner collaborates with healthcare providers, insurance agents, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the Examiner helps protect the organization from financial loss and supports the delivery of fair and efficient claims processing. Ultimately, this role contributes to the integrity and sustainability of the healthcare insurance system by ensuring claims are processed accurately and ethically. Minimum Qualifications: High school diploma or GED Minimum of 2 years experience in claims examination, medical billing, or healthcare insurance processing. Strong understanding of medical terminology, insurance policies, and healthcare billing codes (e.g., ICD-10, CPT). Proficiency with claims management software and Microsoft Office suite. Preferred Qualifications: Associate's degree or Bachelor's degree in health administration, healthcare management, or a related discipline. Certification such as Certified Professional Coder (CPC) or Certified Claims Professional (CCP). Experience working within the health care and social assistance industry or with government healthcare programs. Familiarity with regulatory frameworks such as HIPAA and the Affordable Care Act. Responsibilities: Review and analyze health insurance claims for completeness, accuracy, and compliance with policy terms and regulatory requirements. Verify medical codes, treatment documentation, and billing information to ensure services are properly covered and billed. Investigate and resolve claim discrepancies by communicating with providers, members, and internal departments. Identify and escalate potential fraudulent claims or billing errors to compliance or legal teams. Maintain detailed records of claim evaluations and stay current with healthcare laws and industry standards to support audits and improve processing workflows.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. Training: Monday to Friday 8:00am to 4:30pm Central Time for 4 weeks Training Classes Starting: 3/2/2026 4 week paid training Full-Time position + Benefits In office at 6535 SH 161, Irving, TX or 19100 Ridgewood Parkway, San Antonio, TX What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: Day-to-day processing of claims for accounts: Responsible for processing of claims (medical, dental, vision, and mental health claims) Claims processing and adjudication. Claims research where applicable. Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. Investigation and overpayment administration: Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. Utilize systems to track complaints and resolutions. Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: 2+ years related work experience. Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. High school diploma or GED Knowledge of CPT and ICD-10 coding required. Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. Must possess proven judgment, decision-making skills and the ability to analyze. Ability to learn quickly and multitask. Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. Concise written and verbal communication skills required, including the ability to handle conflict. Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: Some college courses in related fields are a plus. Other experience in processing all types of medical claims helpful. Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: Medical, dental, vision, life and global travel health insurance Income protection benefits: life insurance, Short- and long-term disability programs Leave programs to support personal circumstances. Retirement Savings Plan includes employer contribution and employer match Paid time off, volunteer time off, and 11 holidays Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.