Claim Processor jobs at ProMedica Toledo Hospital

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Claims Production Manager and Supervisor, the Claims Processor Level II will be processing outpatient professional and institutional claims. This includes but is not limited to; lab, radiology, ambulance, behavior health, outpatient COB, dialysis, oncology/chemo, hospital exclusions etc., in an accurate and expedient manner. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Telecommute schedule CalPERS retirement State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Responsible for non-delegated provider claims verification and adjudication. Adjudicate all professional and outpatient claims including COB, denials, and reduction in service notifications. Meet Regulatory Compliance Regulations on turnaround times and claim payments. Read and interpret Medi-Cal/Medicare Fee Schedules. Must be able to make a sound determination if claim is eligible for payment or denial. Interface with other IEHP Departments, when necessary, regarding claims issues. Participate in Claims Department staff meetings, and other activities as needed. Responsible for meeting the performance measurement standards for productivity and accuracy. Any other duties as required to ensure the Health Plan operations are successful. Qualifications Education & Requirements Minimum of two (2) years of experience adjudicating outpatient professional and/or institutional claims preferably in an HMO or Managed Care setting Processing of Medicare, Medi-Cal, or Commercial claims required Proficient in rate applications for Medi-Cal and/or Medicare pricers High school diploma or GED required Key Qualifications ICD-9 and CPT coding and general practices of claims processing Knowledge of capitated managed care environment preferred Microcomputer skills, proficiency in Windows applications preferred Excellent communication and interpersonal skills, strong organizational skills Professional demeanor Must be computer literate, maintain good attendance, and have the right attitude and discipline to work from home Data entry involving computer keyboard and screens, filing, and copying of records and/or correspondence Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range USD $23.98 - USD $30.57 /Hr.

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Claims Production Manager and Supervisor, the Claims Processor Level II will be processing outpatient professional and institutional claims. This includes but is not limited to; lab, radiology, ambulance, behavior health, outpatient COB, dialysis, oncology/chemo, hospital exclusions etc., in an accurate and expedient manner. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Telecommute schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Responsible for non-delegated provider claims verification and adjudication. Adjudicate all professional and outpatient claims including COB, denials, and reduction in service notifications. Meet Regulatory Compliance Regulations on turnaround times and claim payments. Read and interpret Medi-Cal/Medicare Fee Schedules. Must be able to make a sound determination if claim is eligible for payment or denial. Interface with other IEHP Departments, when necessary, regarding claims issues. Participate in Claims Department staff meetings, and other activities as needed. Responsible for meeting the performance measurement standards for productivity and accuracy. Any other duties as required to ensure the Health Plan operations are successful. Qualifications Education & Requirements Minimum of two (2) years of experience adjudicating outpatient professional and/or institutional claims preferably in an HMO or Managed Care setting Processing of Medicare, Medi-Cal, or Commercial claims required Proficient in rate applications for Medi-Cal and/or Medicare pricers High school diploma or GED required Key Qualifications ICD-9 and CPT coding and general practices of claims processing Prefer knowledge of capitated managed care environment Microcomputer skills, proficiency in Windows applications preferred Excellent communication and interpersonal skills, strong organizational skills Professional demeanor Must be computer literate, maintain good attendance, and have the right attitude and discipline to work from home Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range USD $23.98 - USD $30.57 /Hr.

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Handles day-to-day oversight of general, professional, and other liability claims in accordance with Adventist Health's claims program policies and procedures and within an assigned region or scope of responsibility. Maintains up-to-date and accurate claims files, including summaries, action plans, and claims status in the claims data management software, coordinating with market leadership, risk managers, defense counsel, and others. Receives assignments in the form of strategic objectives and is responsible for determining the appropriate tactical approach, resource allocation, scheduling, and goal setting to achieve desired outcomes. Collaborates with a high level of communication and customer service. Job Requirements: Education and Work Experience: * Bachelor's Degree in risk management, legal studies, nursing, or closely related field or equivalent combination of education/related experience: Required * Master's Degree: Preferred * Three years' related experience managing professional and general liability claims within a hospital system, insurance carrier, self-insured environment, law firm setting, or a combination of these: Preferred Licenses/Certifications: * Associate in Claims: Preferred * Chartered Property Casualty Underwriter: Preferred Essential Functions: * Manages a portfolio of claims from first notice through resolution. Coordinates litigation activity, including working closely with defense counsel, attending mediations, and contributing to legal strategy and trial preparation. Reviews attorney invoices and monitors counsel for compliance within organization policies and guidelines. Reviews and analyzes medical records, interviewes witnesses, assists with the discovery process and communicates with facility risk manager regarding evaluation and investigation. * Establishes and adjusts reserves based within organizational authority level. Develops and implements effective settlement strategies, engaging structured settlement professionals when appropriate. Identifies opportunities for subrogation, contribution, and recovery to reduce total claim costs and enhance overall case outcomes. Selects appropriate medical experts for case review. * Coordinates initial notice to reinsurers and provides timely updates on case status. Maintains accurate and detailed claim files in the claims management system, ensuring documentation of activity, decisions, and communications. Provides direction to support staff. * Notifies manager of identified trends or patterns in claims that may indicate systemic risk or opportunities for clinical improvement. Prepares claim summaries, reports, and dashboards for management and participates in claims review meetings. Develops and documents for each claim or lawsuit a plan of action for resolution by settlement, trial, or other means. * Maintains the electronic file including all material communication, correspondence, analysis, expert opinions, interview summaries and all other material documents in accordance with the claims policies and procedures manual. Provides feedback and recommendations, evaluations, litigation trends, department policies and procedures, system-wide claims and litigation processes, and appropriate system risk management issues. * Performs other job-related duties as assigned. Organizational Requirements: Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit ******************************************** for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under the direction of the Claims Production Manager and Supervisor, the Claims Processor Level II will be processing outpatient professional and institutional claims. This includes but is not limited to; lab, radiology, ambulance, behavior health, outpatient COB, dialysis, oncology/chemo, hospital exclusions etc., in an accurate and expedient manner. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. * Competitive salary * Telecommute schedule * State of the art fitness center on-site * Medical Insurance with Dental and Vision * Life, short-term, and long-term disability options * Career advancement opportunities and professional development * Wellness programs that promote a healthy work-life balance * Flexible Spending Account - Health Care/Childcare * CalPERS retirement * 457(b) option with a contribution match * Paid life insurance for employees * Pet care insurance Education & Requirements * Minimum of two (2) years of experience adjudicating outpatient professional and/or institutional claims preferably in an HMO or Managed Care setting * Processing of Medicare, Medi-Cal, or Commercial claims required * Proficient in rate applications for Medi-Cal and/or Medicare pricers * High school diploma or GED required Key Qualifications * ICD-9 and CPT coding and general practices of claims processing * Prefer knowledge of capitated managed care environment * Microcomputer skills, proficiency in Windows applications preferred * Excellent communication and interpersonal skills, strong organizational skills * Professional demeanor * Must be computer literate, maintain good attendance, and have the right attitude and discipline to work from home Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range * $23.98 USD Hourly - $30.57 USD Hourly

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service. We are proud to say that for three years, HMA has been chosen as a ‘Washington's Best Workplaces' by our Staff and PSBJ™. Our vision, ‘Proving What's Possible in Healthcare™,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results. What we are looking for: We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven. What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: ***************** How YOU will make a Difference: As a Claims Specialist, you'll be at the heart of our mission to deliver exceptional service. Working alongside a dedicated team, you'll ensure the accurate and timely processing of medical, dental, vision, and short-term disability claims that HMA administers for our members. Your role goes beyond handling claims, you'll be a key player in shaping a positive healthcare experience for our members. Every claim you interact with helps someone navigate their healthcare journey with confidence, making your work both meaningful and impactful. What YOU will do: Carefully research discrepancies, process returned checks, issue refunds, and manage stop payments with precision. This ensures financial accuracy and builds trust with both clients and members. Manage high-importance claims and vendor billing with urgency and attention to detail. Review and reply to appeals, inquiries, and other communications related to claims. Work with third-party organizations to secure payments on outstanding balances. Process case management and utilization review negotiated claims Spot potential subrogation claims and escalate them appropriately. Actively contribute to team success by assisting colleagues when workloads peak, sharing knowledge, and fostering a collaborative environment. Requirements High school diploma required 3-5+ years of claims processing experience 2+ years of BCBS claims processing experience Strong interpersonal and communication skills Strong attention to detail, with high degree of accuracy and urgency Ability to take initiative and ownership of assigned tasks, working independently with minimal supervision, yet maintain a team-oriented and collaborative approach to problem solving Previous success in a fast-paced environment Benefits Compensation: The base salary range for this position in the greater Seattle area is $28/hr - $32/hr for a level II and varies dependent on geography, skills, experience, education, and other job or market-related factors. While we are looking for level II, we may consider level III for highly qualified candidates. Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law. In addition, HMA provides a generous total rewards package for full-time employees that includes: Seventeen (IC) days paid time off (individual contributors) Eleven paid holidays Two paid personal and one paid volunteer day Company-subsidized medical, dental, vision, and prescription insurance Company-paid disability, life, and AD&D insurances Voluntary insurances HSA and FSA pre-tax programs 401(k)-retirement plan with company match Annual $500 wellness incentive and a $600 wellness reimbursement Remote work and continuing education reimbursements Discount program Parental leave Up to $1,000 annual charitable giving match How we Support your Work, Life, and Wellness Goals At HMA, we believe in recognizing and celebrating the achievements of our dedicated staff. We offer flexibility to work schedules that support people in all time zones across the US, ensuring a healthy work-life balance. Employees have the option to work remotely or enjoy the amenities of our renovated office located just outside Seattle with free parking, gym, and a multitude of refreshments. Our performance management program is designed to elevate career growth opportunities, fostering a collaborative work culture where every team member can thrive. We also prioritize having fun together by hosting in person events throughout the year including an annual all hands, summer picnic, trivia night, and a holiday party. We hire people from across the US (excluding the state of Hawaii and the cities of Los Angeles and San Francisco.) HMA requires a background screen prior to employment. Protected Health Information (PHI) Access Healthcare Management Administrators (HMA); employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures. HMA is an Equal Opportunity Employer. For more information about HMA, visit: *****************

Grow Healthy If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn't just welcomed - it's nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don't just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it's a calling that drives us forward every day. Job Overview A Provider Dispute Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues. Minimum Requirements * HS Diploma or GED * 2+ years of Claims Processing experience in a managed care environment. * Must understand to read and interpret DOFRs and Contracts. * Must have an understanding of how to read a CMS-1500 and UB-04 form. * Must have strong organizational and mathematical skills. Compensation $26.91 - $33.53 hourly Compensation Disclaimer Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives. Benefits & Career Development * Medical, Dental and Vision insurance * 403(b) Retirement savings plans with employer matching contributions * Flexible Spending Accounts * Commuter Flexible Spending * Career Advancement & Development opportunities * Paid Time Off & Holidays * Paid CME Days * Malpractice insurance and tail coverage * Tuition Reimbursement Program * Corporate Employee Discounts * Employee Referral Bonus Program * Pet Care Insurance Job Advertisement & Application Compliance Statement AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

Grow Healthy If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn't just welcomed - it's nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don't just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it's a calling that drives us forward every day. Job Overview The Claims Examiner II is responsible for analyzing and adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. May resolve claims payment issues as presented through the Provider Dispute Resolution (PDR) process or from claims incidents/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payment. Collaborates with other departments and/or providers in the successful resolution of claims-related issues. Minimum Requirements * HS Diploma or GED * Minimum of 3 years of Claims Processing experience in a managed care environment. * Experience in reading and interpreting DOFRs and Contracts is required. * Experience in reading CMS-1500 and UB-04 forms is required. Compensation $26.91 - $33.53 hourly Compensation Disclaimer Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives. Benefits & Career Development * Medical, Dental and Vision insurance * 403(b) Retirement savings plans with employer matching contributions * Flexible Spending Accounts * Commuter Flexible Spending * Career Advancement & Development opportunities * Paid Time Off & Holidays * Paid CME Days * Malpractice insurance and tail coverage * Tuition Reimbursement Program * Corporate Employee Discounts * Employee Referral Bonus Program * Pet Care Insurance Job Advertisement & Application Compliance Statement AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

Grow Healthy If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn't just welcomed - it's nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don't just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it's a calling that drives us forward every day. Job Overview The Claims Examiner II is responsible for analyzing and adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. May resolve claims payment issues as presented through the Provider Dispute Resolution (PDR) process or from claims incidents/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payment. Collaborates with other departments and/or providers in the successful resolution of claims-related issues. Minimum Requirements * HS Diploma or GED * Minimum of 3 years of Claims Processing experience in a managed care environment. * Experience in reading and interpreting DOFRs and Contracts is required. * Experience in reading CMS-1500 and UB-04 forms is required. Compensation $26.91 - $33.53 hourly Compensation Disclaimer Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives. Benefits & Career Development * Medical, Dental and Vision insurance * 403(b) Retirement savings plans with employer matching contributions * Flexible Spending Accounts * Commuter Flexible Spending * Career Advancement & Development opportunities * Paid Time Off & Holidays * Paid CME Days * Malpractice insurance and tail coverage * Tuition Reimbursement Program * Corporate Employee Discounts * Employee Referral Bonus Program * Pet Care Insurance Job Advertisement & Application Compliance Statement AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

Job Description An Account Resolution Specialist I is responsible for researching and identifying unpaid, partially paid, incorrectly paid or denied claims. They must follow-up with insurance carriers verbally or via on-line tools and properly discuss the problem with the knowledge of how to negotiate payment/additional payments on all claims. In the event the needs arise, they will also resubmit a corrected claim and/or follow-up with patients regarding the issue(s) as needed. Minimum Education Must have a high-school diploma or a GED. Minimum Work Experience No prior work experience in this related field is required at this level. Required Skills Customer service Must have general Microsoft Office (Word, Excel, PPT, and Outlook) experience. Ability to manage their time in order to meet job requirements. Ability to review an account and come to a decision as to what the proper solution would be to resolve the account. Must be a team player. Screening Requirements: Drug Screen Tuberculosis Test Background Check Physical Exam Respirator Fit Eligible Benefits: Medical, Dental and Vision *Excellent Low Premiums!*- No copays or Deductibles when utilizing MCCH services! Life Insurance *ZERO premium* Retirement Plan Paid Time Off Bereavement Bridge Coverage *ZERO premium for self-coverage when enrolled in medical coverage Tuition Reimbursement Our Mission: To improve the lives of those we serve by providing outstanding care and services through our confident, compassionate and exceptional healthcare professionals. Our Vision: To be chosen by our community and expanded service region based on proven outcomes as the trusted provider to care for their families, friends and neighbors. Our Values: Competence, Excellence, Compassion, Respect and Integrity.

Job DescriptionDescription: Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Claims Examiner III to join our growing company with many internal opportunities. Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare health plan is looking for people like you who value excellence, integrity, care and innovation. As an employee, you'll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity. Align your career goals with Verda Healthcare, Inc. and we will support you all the way. Position Overview The Claims Examiner III performs advanced administrative, operational, and customer support duties that require independent initiative and sound judgment. This position is responsible for the analysis and adjudication of medical claims within a managed care environment. The role includes processing payment reconciliations and adjustments related to retroactive contract rates and fee schedule changes, as well as identifying root causes of claims payment errors and reporting them to management. The Claims Examiner III also manages provider inquiries and supports resolution efforts across departments. This position reports to: Claims Operations Manager. Responsibilities: · Analyze and adjudicate complex medical claims in compliance with CMS guidelines and health plan policies. · Review and apply appropriate fee schedules, contracts, and benefit plans. · Perform claim payment reconciliations and retroactive adjustments. · Identify patterns and root causes of payment discrepancies and escalate issues as needed. · Respond to provider inquiries and coordinate with internal teams for resolution. · Maintain documentation and track resolution outcomes. · Ensure compliance with regulatory, contractual, and internal policies. · Recommend process improvements based on claim trends and data analysis. · Support training initiatives for new staff and peers as subject matter experts. Requirements: Minimum Qualifications · High school diploma or GED required. Associate or bachelor's degree preferred. · Minimum of 3-5 years of experience in claims processing and adjudication, preferably within Medicare Advantage or managed care settings. · Knowledge of CPT, HCPCS, ICD-10 coding, and CMS regulations. · Strong analytical and problem-solving skills. · Proficient in claims systems (e.g., Plexis, Facets) and Microsoft Office tools. · Ability to handle confidential information in compliance with HIPAA. Professional Competencies · Strong attention to detail and accuracy · Excellent verbal and written communication · Customer service-oriented with a collaborative mindset · Ability to work independently and prioritize tasks · Commitment to continuous learning and quality improvement Verda cares deeply about the future, growth, and well-being of its employees. Join our team today! Job Type: Full-time Benefits: 401(k) Paid time off (vacation, holiday, sick leave) Health insurance Dental Insurance Vision insurance Life insurance Schedule: Full-time onsite (100% in-office) Hours of operations: 9am - 6pm Standard business hours Monday to Friday/weekends as needed Occasional travel may be required for meetings and training sessions. Ability to commute/relocate: Reliably commute or planning to relocate before starting work (Required) PHYSICAL DEMANDS Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds. * Other duties may be assigned in support of departmental goals.

Snaggle Dental West Monroe, LA 71291 Job details Salary: Starting from $16.00-$20.00/hourly Pay is based on experience and qualifications. **incentives after training vary and are based on performance Job Type: Full-time Full Job Description With our hearts, minds, and hands, we build better smiles, better relationships, and better lives. Living this purpose over the last 25 years has allowed us to create a world-class dental organization that continues to grow. At every turn, you will see our continued investment in leadership, the community, and advanced technologies. Do you want to be a part of developing one of the leading models of dental care in Louisiana? Do you thrive in a fast-paced, progressive environment? The role of the Insurance Claims Specialist could be for you! Please go to WWW.PEACHTREEDENTAL.COM to complete your online application and assessments or use the following URL: ********************************************** Qualifications High school or equivalent (Required) Takes initiative. Has excellent verbal and written skills. Ability to manage all public dealings in a professional manner. Ability to recognize problems and problem solve. Ability to accept feedback and willingness to improve. Ability to set goals, create plans, and convert plans into action. Is a Brand ambassador, both in and outside of the facility. Benefits offered for Full-time Insurance Claims Specialists: Medical, Dental, Vision Benefits Dependent Care & Healthcare Flexible Spending Account Simple IRA With Employer Match Basic Life, AD&D & Supplemental Life Insurance Short-term & Long-term Disability Perks & Rewards for Full-time Insurance Claims Specialists: Competitive pay + bonus Paid Time Off & Sick time 6 paid Holidays a year

Family Health Care is currently seeking applications for the position of Pharmacy 340B Claims Specialist! General Function: This position functions at the highest level (III) in the series of Pharmacy Technician roles within Family Health Care. The individual in this role is a "work-leader" serving as the expert on prescription claims reimbursement and performing self-auditing for the pharmacy department. This individual will ensure prescription claim integrity by having advanced knowledge of claim requirements for the various pharmacy benefit managers (PBM) and shall use that information to identify areas of improvement by performing targeted claim audits and will provide education to the pharmacy staff on billing requirements, when needed. Responsibilities: * Acts as pharmacy claims auditor and will audit claims daily into order to track claims accuracy, trends, anomalies and other critical information to help BFHC ensuring appropriate reimbursement while mitigating organizational risk for claims remediations resulting from claim processing errors. * Acts as pharmacy 340B claims auditor and audits claims on a scheduled basis into order to track 340B claims accuracy, trends, anomalies, and other critical information to help BFHC maintain 340B claim integrity while ensuring adherence to 340B policies, procedures, rules and regulations. * Ensures timely and accurate billing/collections of all pharmacy charges and reimbursement activities through the use of reporting and reconciliation. * Ensures integrity if financial reports and provides necessary reports to the finance department upon request. * Assists the Chief Pharmacist and pharmacy staff in the research, development and implementation of new and existing pharmacy services. Location(s): White Cloud, MI Employment Type: Full Time Exempt/Non-Exempt: Non-Exempt Benefits: Competitive wage and excellent benefits package. FHC is an eligible organization for State and Federal Loan Repayment Programs. Family Health Care is an Equal Opportunity Employer.

Family Health Care is currently seeking applications for the position of Pharmacy 340B Claims Specialist! General Function: This position functions at the highest level (III) in the series of Pharmacy Technician roles within Family Health Care. The individual in this role is a “work-leader” serving as the expert on prescription claims reimbursement and performing self-auditing for the pharmacy department. This individual will ensure prescription claim integrity by having advanced knowledge of claim requirements for the various pharmacy benefit managers (PBM) and shall use that information to identify areas of improvement by performing targeted claim audits and will provide education to the pharmacy staff on billing requirements, when needed. Responsibilities: Acts as pharmacy claims auditor and will audit claims daily into order to track claims accuracy, trends, anomalies and other critical information to help BFHC ensuring appropriate reimbursement while mitigating organizational risk for claims remediations resulting from claim processing errors. Acts as pharmacy 340B claims auditor and audits claims on a scheduled basis into order to track 340B claims accuracy, trends, anomalies, and other critical information to help BFHC maintain 340B claim integrity while ensuring adherence to 340B policies, procedures, rules and regulations. Ensures timely and accurate billing/collections of all pharmacy charges and reimbursement activities through the use of reporting and reconciliation. Ensures integrity if financial reports and provides necessary reports to the finance department upon request. Assists the Chief Pharmacist and pharmacy staff in the research, development and implementation of new and existing pharmacy services. Location(s): White Cloud, MI Employment Type: Full Time Exempt/Non-Exempt: Non-Exempt Benefits: Competitive wage and excellent benefits package. FHC is an eligible organization for State and Federal Loan Repayment Programs. Family Health Care is an Equal Opportunity Employer.

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Covered California Claims (CCA) Manager, the CCA Claims Specialist is responsible for analyzing, managing, and investigating complex and high-dollar healthcare claims that require in-depth research to determine accuracy and mitigate payment errors. The Claims Specialist is also responsible for adjusting first-pass and post-pay claims that result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues. This position collaborates with internal stakeholders, assists with claim audits (internal and regulatory) and utilizes strong analytical skills and independent judgement skills to make effective and accurate decisions. This position will also be responsible for responding to inquiries from the Provider Payment Resolution team on claims that may have been paid incorrectly. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Telecommute schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Work effectively with other departments (i.e., Special Investigation Unit, Provider Payment Resolution team, and other departments/stakeholders) to investigate and identify fraud, respond to escalated provider inquiries timely, and support the claims process. Investigate and process complex and high-dollar claims determining accuracy and making timely decisions. Advise leadership and internal business units (as applicable) of findings and outcomes on identified claim issues. Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust/adjudicate as needed in the Health Rules Processing system and other platforms. Research claims that may have been paid incorrectly and communicate findings for adjustment. Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations, contracted amounts, etc.) ensuring that all relevant information is considered. Assist with internal and regulatory claim audits, reviewing claim accuracy. Identify trends and recommend improvements to IEHP's claim processing system. Analyze and investigate insurance claims to discover or prevent fraud. Be an active participant in the Claims Department's initiatives and participate in Claims Huddles, etc. Remain current with all claim processing changes/updates (i.e. internal processes, regulatory guidelines). Perform any other duties as required to ensure Health Plan operations and department business needs are successful. Qualifications Education & Requirements Three (3) years of experience in examining and processing complex and high-dollar institutional and professional claims Experience in a managed care environment helpful. Commercial, Exchange, and Medicare preferred High school diploma or GED required Associate's degree from an accredited institution preferred Key Qualifications ICD-9/ ICD-10 and CPT coding and general practices of claims processing CMS/DMHC and Affordable Care Act regulations and guidelines Commercial line of business specifically Covered California/Exchange Excellent communication and interpersonal skills Excellent analytical, critical thinking, customer service, and organizational skills Ability to think critically with the capacity to work independently All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range USD $25.90 - USD $33.02 /Hr.

Peach Tree Dental - Monroe, LA Monroe, LA 71270 Job details Salary: Starting from $16.00-$20.00/hourly Pay is based on experience and qualifications. **incentives after training vary and are based on performance Job Type: Full-time Full Job Description With our hearts, minds, and hands, we build better smiles, better relationships, and better lives. Living this purpose over the last 25 years has allowed us to create a world-class dental organization that continues to grow. At every turn, you will see our continued investment in leadership, the community, and advanced technologies. Do you want to be a part of developing one of the leading models of dental care in Louisiana? Do you thrive in a fast-paced, progressive environment? The role of the Insurance Claims Specialist could be for you! Please go to WWW.PEACHTREEDENTAL.COM to complete your online application and assessments or use the following URL: ********************************************** Qualifications High school or equivalent (Required) Takes initiative. Has excellent verbal and written skills. Ability to manage all public dealings in a professional manner. Ability to recognize problems and problem solve. Ability to accept feedback and willingness to improve. Ability to set goals, create plans, and convert plans into action. Is a Brand ambassador, both in and outside of the facility. Benefits offered for Full-time Insurance Claims Specialists: Medical, Dental, Vision Benefits Dependent Care & Healthcare Flexible Spending Account Simple IRA With Employer Match Basic Life, AD&D & Supplemental Life Insurance Short-term & Long-term Disability Perks & Rewards for Full-time Insurance Claims Specialists: Competitive pay + bonus Paid Time Off & Sick time 6 paid Holidays a year

Salary: $16.00 - $20.00 Insurance Claims Specialist Peach Tree Dental - Monroe, West Monroe, Ruston, Jonesboro Job Details: Salary: Starting from $16.00-$20.00/hourly Pay is based on experience, qualifications, and desired location. **incentives after training vary and are based on performance Job Type:Full-time Qualifications For Insurance Claims Specialists: High school or equivalent (Required) Takes initiative. Has excellent verbal and written skills. Ability to manage all public dealings in a professional manner. Ability to recognize problems and problem solve. Ability to accept feedback and willingness to improve. Ability to set goals, create plans, and convert plans into action. Is a Brand ambassador, both in and outside of the facility. Benefits Offered For Full-Time Insurance Claims Specialists: Medical, Dental, Vision Benefits Dependent Care & Healthcare Flexible Spending Account Simple IRA With Employer Match Basic Life, AD&D & Supplemental Life Insurance Short-term & Long-term Disability Perks & Rewards For Full-Time Insurance Claims Specialists: Competitive pay + bonus Paid Time Off & Sick time 6 paid Holidays a year Full Job Description: With our hearts, minds, and hands, we build better smiles, better relationships, and better lives. Living this purpose over the last 25 years has allowed us to create a world-class dental organization that continues to grow. At every turn, you will see our continued investment in leadership, the community, and advanced technologies. Do you want to be a part of developing one of the leading models of dental care in Louisiana? Do you thrive in a fast-paced, progressive environment? The role of the Insurance Claims Specialist could be for you! Please go to WWW.PEACHTREEDENTAL.COMto complete your online application and assessments or use the following URL:**********************************************

Job DescriptionSalary: Starting at $21.00 p/hr Family Health Care is currently seeking applications for the position of Pharmacy 340B Claims Specialist! General Function: This position functions at the highest level (III) in the series of Pharmacy Technician roles within Family Health Care. The individual in this role is a work-leader serving as the expert on prescription claims reimbursement and performing self-auditing for the pharmacy department. This individual will ensure prescription claim integrity by having advanced knowledge of claim requirements for the various pharmacy benefit managers (PBM) and shall use that information to identify areas of improvement by performing targeted claim audits and will provide education to the pharmacy staff on billing requirements, when needed. Responsibilities: Acts as pharmacy claims auditor and will audit claims daily into order to track claims accuracy, trends, anomalies and other critical information to help BFHC ensuring appropriate reimbursement while mitigating organizational risk for claims remediations resulting from claim processing errors. Acts as pharmacy 340B claims auditor and audits claims on a scheduled basis into order to track 340B claims accuracy, trends, anomalies, and other critical information to help BFHC maintain 340B claim integrity while ensuring adherence to 340B policies, procedures, rules and regulations. Ensures timely and accurate billing/collections of all pharmacy charges and reimbursement activities through the use of reporting and reconciliation. Ensures integrity if financial reports and provides necessary reports to the finance department upon request. Assists the Chief Pharmacist and pharmacy staff in the research, development and implementation of new and existing pharmacy services. Location(s): White Cloud, MI Employment Type:Full Time Exempt/Non-Exempt: Non-Exempt Benefits: Competitive wage and excellent benefits package. FHC is an eligible organization for State and Federal Loan Repayment Programs. Family Health Care is an Equal Opportunity Employer.

Peach Tree Dental - Ruston Ruston, LA 71270 Job details Salary: Starting from $14.00-$18.00/hourly Pay is based on experience and qualifications. **incentives after training vary and are based on performance Job Type: Full-time Full Job Description With our hearts, minds, and hands, we build better smiles, better relationships, and better lives. Living this purpose over the last 25 years has allowed us to create a world-class dental organization that continues to grow. At every turn, you will see our continued investment in leadership, the community, and advanced technologies. Do you want to be a part of developing one of the leading models of dental care in Louisiana? Do you thrive in a fast-paced, progressive environment? The role of the Insurance Claims Specialist could be for you! Please go to WWW.PEACHTREEDENTAL.COM to complete your online application and assessments or use the following URL: ********************************************** Qualifications High school or equivalent (Required) Takes initiative. Has excellent verbal and written skills. Ability to manage all public dealings in a professional manner. Ability to recognize problems and problem solve. Ability to accept feedback and willingness to improve. Ability to set goals, create plans, and convert plans into action. Is a Brand ambassador, both in and outside of the facility. Benefits offered for Full-time Insurance Claims Specialists: Medical, Dental, Vision Benefits Dependent Care & Healthcare Flexible Spending Account Simple IRA With Employer Match Basic Life, AD&D & Supplemental Life Insurance Short-term & Long-term Disability Perks & Rewards for Full-time Insurance Claims Specialists: Competitive pay + bonus Paid Time Off & Sick time 6 paid Holidays a year

Peach Tree Dental - Jonesboro Jonesboro, LA 71251 Job details Salary: Starting from $16.00-$20.00/hourly Pay is based on experience and qualifications. **incentives after training vary and are based on performance Job Type: Full-time Full Job Description With our hearts, minds, and hands, we build better smiles, better relationships, and better lives. Living this purpose over the last 25 years has allowed us to create a world-class dental organization that continues to grow. At every turn, you will see our continued investment in leadership, the community, and advanced technologies. Do you want to be a part of developing one of the leading models of dental care in Louisiana? Do you thrive in a fast-paced, progressive environment? The role of the Insurance Claims Specialist could be for you! Please go to WWW.PEACHTREEDENTAL.COM to complete your online application and assessments or use the following URL: ********************************************** Qualifications High school or equivalent (Required) Takes initiative. Has excellent verbal and written skills. Ability to manage all public dealings in a professional manner. Ability to recognize problems and problem solve. Ability to accept feedback and willingness to improve. Ability to set goals, create plans, and convert plans into action. Is a Brand ambassador, both in and outside of the facility. Benefits offered for Full-time Insurance Claims Specialists: Medical, Dental, Vision Benefits Dependent Care & Healthcare Flexible Spending Account Simple IRA With Employer Match Basic Life, AD&D & Supplemental Life Insurance Short-term & Long-term Disability Perks & Rewards for Full-time Insurance Claims Specialists: Competitive pay + bonus Paid Time Off & Sick time 6 paid Holidays a year