Reviewer jobs at South Shore Health - 23 jobs

at HQ Home Care-Certified Purpose: The Quality Systems Reviewer assists in the implementation of the Agencyï ½s Performance Improvement, Risk Management, Infection Control, and OASIS programs to ensure compliance with JCAHO, Federal, and New York State requirements. Responsibilities: 1.Performs Start-of-Care Audits including 485 reviews daily. 2.Audits OASIS Resumption of Care, Follow-up and Discharge forms daily. 3.Performs pre-billing reviews. 4.Develops Performance Improvement Reports. 5.Participates in documentation reviews for competencies. 6.Provides feedback to Team Leaders via program dashboard on quality and process measures.Participates in quarterly Utilization Review. 7.Prepares reports to DQS and Clinical Team as appropriate. 8.Provides direction in performance improvement, risk management, infection control and OASIS to field and administrative staff. 9.Maintain and Model REACH Values (Respect, Excellence, Accountability, Compassion, Honor). 10.Demonstrates regular, reliable and predictable attendance. 11.Performs other duties as required. Other Information: Education and Experience Requirements: Bachelorï ½s degree in nursing or equivalent experience. Minimum of three (3) yearsï ½ Home Care experience. QAPI experience 1-3 years Minimum Knowledge, Skills and Abilities Requirements: ï ½Proficient computers skills including Microsoft Word and Excel. ï ½Extensive knowledge of certified home care regulations and documentation requirements or experience in quality systems. ï ½Excellent organizational, customer service, communication and auditing skills License, Registration, or Certification Requirements: Current New York State a Registered Nurse license. PREFER: QAPI certificate. Credentials:RN,BLS Company: HQ Home Care-Certified Org Unit: 1694 Department: Home Care Admin Exempt: No Salary Range: $36.53 - $67.90 Hourly

*Purpose: *The Quality Systems Reviewer assists in the implementation of the Agency s Performance Improvement, Risk Management, Infection Control, and OASIS programs to ensure compliance with JCAHO, Federal, and New York State requirements. Responsibilities: 1.Performs Start-of-Care Audits including 485 reviews daily. 2.Audits OASIS Resumption of Care, Follow-up and Discharge forms daily. 3.Performs pre-billing reviews. 4.Develops Performance Improvement Reports. 5.Participates in documentation reviews for competencies. 6.Provides feedback to Team Leaders via program dashboard on quality and process measures.Participates in quarterly Utilization Review. 7.Prepares reports to DQS and Clinical Team as appropriate. 8.Provides direction in performance improvement, risk management, infection control and OASIS to field and administrative staff. 9.Maintain and Model REACH Values (Respect, Excellence, Accountability, Compassion, Honor). 10.Demonstrates regular, reliable and predictable attendance. 11.Performs other duties as required. Other Information: *Education and Experience Requirements: * * Bachelor s degree in nursing or equivalent experience. * Minimum of three (3) years Home Care experience. * QAPI experience 1-3 years *Minimum Knowledge, Skills and Abilities Requirements:* Proficient computers skills including Microsoft Word and Excel. Extensive knowledge of certified home care regulations and documentation requirements or experience in quality systems. Excellent organizational, customer service, communication and auditing skills *License, Registration, or Certification Requirements:* * Current New York State a Registered Nurse license. * PREFER: QAPI certificate. Credentials:RN,BLS Company: HQ Home Care-Certified Org Unit: 1694 Department: Home Care Admin Exempt: No Salary Range: $36.53 - $67.90 Hourly We are an equal opportunity employer Qualified applicants are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other classification protected under applicable Federal, State or Local law. We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation or our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at ************ (for reasonable accommodation requests only). Please provide all information requested to ensure that you are considered for current or future opportunities.

QUALIFICATIONS Qualified candidates must have one to three years prior office or relevant experience. Ability to work on various assignments simultaneously and to communicate tactfully, verbally and in writing with department heads, managers, coworkers and vendors to resolve problems and negotiate resolutions. Working knowledge of computers, internet access, and the ability to navigate within an automated systems as well as a variety of software packages such as Outlook, Excel and Word. EDUCATION Completion of high school or basic education equivalency preferred. SPECIAL INSTRUCTIONS TO CANDIDATES EOE/AA M/F/D/V

QUALIFICATIONS * Qualified candidates must have one to three years prior office or relevant experience. * Ability to work on various assignments simultaneously and to communicate tactfully, verbally and in writing with department heads, managers, coworkers and vendors to resolve problems and negotiate resolutions. * Working knowledge of computers, internet access, and the ability to navigate within an automated systems as well as a variety of software packages such as Outlook, Excel and Word. EDUCATION * Completion of high school or basic education equivalency preferred. SPECIAL INSTRUCTIONS TO CANDIDATES * EOE/AA M/F/D/V

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and billing, analyzing inpatient DRG claims based on industry standard inpatient coding guidelines, and supporting the Office of the Chief Medical Officer in managing disputes related to clinical claim reviews. This position is a production-based role with production and quality metric goals. What you'll do: * Review provider disputes for DRG Coding and Clinical Validation (MS and APR) * Review and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met. * Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures * Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including troubleshooting and review for data accuracy. * Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests. * Create and present education to Expert Claim Review Teams and other departments dispute findings. * Research and analysis of content for DRG reviews. * Use of strong coding and industry knowledge to create and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales * Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities. * Support for client facing teams as needed relating to client inquiries related to provider disputes. * Utilize the most up-to-date approved Zelis medical coding sources for claim review maintenance. * Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends. * Ensure adherence to quality assurance guidelines. * Monitor, research, and summarize trends, coding practices, and regulatory changes. * Actively contribute new ideas and support ad hoc projects, including time-sensitive requests. * Ensure adherence to quality assurance guidelines. * Maintain awareness of and ensure adherence to ZELIS standards regarding privacy. What you'll bring to Zelis: * 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred * Current, active Inpatient Coding Certification required (ie. CCS, CIC,RHIA, RHIT, CPC or equivalent credentialing). * Registered Nurse licensure preferred * Bachelor's Degree Preferred in business, healthcare, or technology preferred. * Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers * Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs * Understanding of hospital coding and billing rules * Clinical skills to evaluate appropriate Medical Record Coding * Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner. * Background and/or understanding of the healthcare industry. * Knowledge of National Medicare and Medicaid regulations. * Knowledge of payer reimbursement policies. * Creative problem-solving skills, leveraging insights and input from other parts of an organization. * Consistently demonstrate ability to act and react swiftly to continuous challenges and changes. * Excellent analytical skills with data and analytics related solutions. * Excellent communication skills. * Strong organization and project/process management skills. * Strong initiative, self-directed and self-motivation. * Good negotiation, problem solving, planning and decision-making skills. * Ability to manage projects simultaneously and achieve goals. * Excellent follow through, attention to detail, and time management skills. Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Base Salary Range $95,000.00 - $127,000.00 At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role. Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************. Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

Our promise to you: Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. All the benefits and perks you need for you and your family: * Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance * Paid Time Off from Day One * 403-B Retirement Plan * 4 Weeks 100% Paid Parental Leave * Career Development * Whole Person Well-being Resources * Mental Health Resources and Support * Pet Benefits Schedule: Full time Shift: Day (United States of America) Address: 3100 E FLETCHER AVE City: TAMPA State: Florida Postal Code: 33613 Job Description: * Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients. * Transcribes documentation clarifications as appropriate to ensure documentation compliance. * Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff. * Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation. * Collaborates with health information management staff to resolve discrepancies with diagnostic assignments and other coding issues. The expertise and experiences you'll need to succeed: QUALIFICATION REQUIREMENTS: Bachelor's of Nursing (Required), Master'sAdult Acute Care Nurse Practitioner (ACNPC) - EV Accredited Issuing Body, Certified Clinical Documentation Specialist (CCDS) - EV Accredited Issuing Body, Certified Coding Specialist (CCS) - EV Accredited Issuing Body, Certified Documentation Improvement Practitioner (CDIP) - EV Accredited Issuing Body, Physician Assistant (PA) - EV Accredited Issuing Body, Registered Nurse (RN) - EV Accredited Issuing Body Pay Range: $66,170.74 - $123,073.07 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

**Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As an Occupational Therapist, Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. Collaboration Opportunities: + Routinely interacts with leadership and management staff, Physicians, and and other CR's whenever input is needed or required. Job Summary Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process. Job Description + Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria. + Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff. + Conducts regular audits, as assigned, to ensure guidelines are applied appropriately. + In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer. In States where allowed, will make denial determinations as a specific case warrants. + Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale. + Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plans required timeframes. + Documents all communication with medical office staff and/or treating provider. + Practices and maintains the principles of utilization management by adhering to policies and procedures. + Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. **The Experience You'll Need (Required):** + Current, unrestricted state licensure as a Occupational Therapist + A occupational therapist must hold a state license in occupational therapy and hold an occupational therapy degree from an accredited education program and pass the national certification examination. + 5+ years clinical experience is preferred + Strong interpersonal and communication skills. + Strong clinical, communication, and organizational skills + Energetic and curious with a passion for quality and value in health care + Computer Proficiency + Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. + No history of disciplinary or legal action by a state medical board To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview At Zelis, the Itemized Bill and Clinical Chart Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to itemized bill review and clinical claim reviews. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and billing guidelines as it relates to the Itemized Bill Review (IBR) product and Clinical Chart Review (CCR) product on industry standard coding guidelines and clinical policies, supporting the Office of the Chief Medical Officer in managing disputes related to claim reviews. This position will also be responsible for being a resource for the entire organization regarding IBR and CCR claims. This is a production-based role with production and quality metric goals. What you'll do: * Review provider disputes for Itemized Bill Review (IBR) and Clinical Chart Review (CCR) and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met. * Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures * Serve as subject matter expert for the Expert Claim Review Team on day-to day activities including troubleshooting and review for data accuracy. * Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests. * Create and present education to Expert Claim Review Teams and other departments dispute findings. * Research and analysis of content for bill review. * Use of strong coding and industry knowledge to create and maintain bill review content, including but not limited CCR Review Guidelines and Templates, Itemized Bill Review Coding guidelines and Dispute Rationales * Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities. * Support for client facing teams as needed relating to client inquiries related to provider disputes. * Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance. * Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends. * Ensure adherence to quality assurance guidelines. * Monitor, research, and summarize trends, coding practices, and regulatory changes. * Actively contribute new ideas and support ad hoc projects, including time-sensitive requests. * Ensure adherence to quality assurance guidelines. * Maintain awareness of and ensure adherence to ZELIS standards regarding privacy. What you'll bring to Zelis * 5+ years reviewing and/or auditing itemized bill review and clinical chart review claims preferred * Current, active Outpatient Coding Certification required (such as CPC, CCS, or equivalent credentialing). * Registered Nurse licensure preferred * Bachelor's Degree Preferred in business, healthcare, or technology preferred. * Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers * Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs * Understanding of hospital coding and billing rules * Clinical skills to evaluate appropriate Medical Record Coding * Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner. * Background and/or understanding of the healthcare industry. * Knowledge of National Medicare and Medicaid regulations. * Knowledge of payer reimbursement policies. * Creative problem-solving skills, leveraging insights and input from other parts of an organization. * Consistently demonstrate ability to act and react swiftly to continuous challenges and changes. * Excellent analytical skills with data and analytics related solutions. * Excellent communication skills. * Strong organization and project/process management skills. * Strong initiative, self-directed and self-motivation. * Good negotiation, problem solving, planning and decision-making skills. * Ability to manage projects simultaneously and achieve goals. * Excellent follow through, attention to detail, and time management skills. Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Base Salary Range $71,000.00 - $95,000.00 At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role. Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************. Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Our promise to you: Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. All the benefits and perks you need for you and your family: * Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance * Paid Time Off from Day One * 403-B Retirement Plan * 4 Weeks 100% Paid Parental Leave * Career Development * Whole Person Well-being Resources * Mental Health Resources and Support * Pet Benefits Schedule: Full time Shift: Day (United States of America) Address: 900 HOPE WAY City: ALTAMONTE SPRINGS State: Florida Postal Code: 32714 Job Description: * Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients. * Transcribes documentation clarifications as appropriate to ensure documentation compliance. * Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff. * Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation. * Collaborates with health information management staff to resolve discrepancies with diagnostic assignments and other coding issues. * Completes well-timed follow-up case reviews on all cases, prioritizing those with clinical documentation clarifications. * Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities. * Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency. * Assists in new hire orientation through precepting and mentoring. * Maintains regional productivity standards and demonstrates competence on compliance audit scores. * Maintains a 97% physician response rate to all valid clarifications. * Annual participation in Advanced Practice call. * Maintains CCDS credentialing. * Other duties as assigned. * Reviews concurrent medical records for documentation compliance, including completeness, accuracy and quality. Inputs data accurately and concisely into assigned software, resulting in accurate metrics obtained through the reconciliation process. The expertise and experiences you'll need to succeed: QUALIFICATION REQUIREMENTS: Bachelor's of Nursing (Required), Master'sAdult Acute Care Nurse Practitioner (ACNPC) - EV Accredited Issuing Body, Certified Clinical Documentation Specialist (CCDS) - EV Accredited Issuing Body, Certified Coding Specialist (CCS) - EV Accredited Issuing Body, Certified Documentation Improvement Practitioner (CDIP) - EV Accredited Issuing Body, Physician Assistant (PA) - EV Accredited Issuing Body, Registered Nurse (RN) - EV Accredited Issuing Body Pay Range: $66,170.74 - $123,073.07 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

The trainee will review behavior intervention plans (BIPs) to ensure alignment with current data and treatment goals. This includes assessing the effectiveness of interventions, adjusting reinforcement schedules, modifying antecedent strategies, and ensuring plans are clearly written and practical for implementation. Requirements Strong understanding of functional behavior assessments and behavior plans Knowledge of proactive and reactive intervention strategies Ability to analyze behavior data and assess intervention effectiveness Proficiency in writing clear and comprehensive intervention plans Collaboration with the clinical team to ensure ethical and effective interventions

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview At Zelis, the Itemized Bill and Clinical Chart Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to itemized bill review and clinical claim reviews. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and billing guidelines as it relates to the Itemized Bill Review (IBR) product and Clinical Chart Review (CCR) product on industry standard coding guidelines and clinical policies, supporting the Office of the Chief Medical Officer in managing disputes related to claim reviews. This position will also be responsible for being a resource for the entire organization regarding IBR and CCR claims. This is a production-based role with production and quality metric goals. What you'll do: * Review provider disputes for Itemized Bill Review (IBR) and Clinical Chart Review (CCR) and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met. * Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures * Serve as subject matter expert for the Expert Claim Review Team on day-to day activities including troubleshooting and review for data accuracy. * Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests. * Create and present education to Expert Claim Review Teams and other departments dispute findings. * Research and analysis of content for bill review. * Use of strong coding and industry knowledge to create and maintain bill review content, including but not limited CCR Review Guidelines and Templates, Itemized Bill Review Coding guidelines and Dispute Rationales * Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities. * Support for client facing teams as needed relating to client inquiries related to provider disputes. * Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance. * Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends. * Ensure adherence to quality assurance guidelines. * Monitor, research, and summarize trends, coding practices, and regulatory changes. * Actively contribute new ideas and support ad hoc projects, including time-sensitive requests. * Ensure adherence to quality assurance guidelines. * Maintain awareness of and ensure adherence to ZELIS standards regarding privacy. What you'll bring to Zelis * 5+ years reviewing and/or auditing itemized bill review and clinical chart review claims preferred * Current, active Outpatient Coding Certification required (such as CPC, CCS, or equivalent credentialing). * Registered Nurse licensure preferred * Bachelor's Degree Preferred in business, healthcare, or technology preferred. * Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers * Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs * Understanding of hospital coding and billing rules * Clinical skills to evaluate appropriate Medical Record Coding * Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner. * Background and/or understanding of the healthcare industry. * Knowledge of National Medicare and Medicaid regulations. * Knowledge of payer reimbursement policies. * Creative problem-solving skills, leveraging insights and input from other parts of an organization. * Consistently demonstrate ability to act and react swiftly to continuous challenges and changes. * Excellent analytical skills with data and analytics related solutions. * Excellent communication skills. * Strong organization and project/process management skills. * Strong initiative, self-directed and self-motivation. * Good negotiation, problem solving, planning and decision-making skills. * Ability to manage projects simultaneously and achieve goals. * Excellent follow through, attention to detail, and time management skills. Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Base Salary Range $71,000.00 - $95,000.00 At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role. Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************. Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients. Conduct reviews on inpatient DRG claims as they compare with medical records utilizing ICD-10 Official Coding Guidelines, AHA Coding Clinic evidence based clinical criteria and client specific coverage policies. What you'll do: * Perform comprehensive inpatient DRG validation Quality Assurance reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc. * Implement and conduct quality assurance program to ensure accurate results to our clients * Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures * Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization * Prepare and conduct training for new team members * Identify new DRG coding concepts to expand the DRG product * Meet and/or exceed all internal and department productivity and quality standards * Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant * Recommend efficiencies and process improvements to improve departmental procedures * Maintain awareness of and ensure adherence to Zelis standards regarding privacy What you'll bring to Zelis: * Registered Nurse licensure preferred * Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT) * 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred * Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers * Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs * Strong understanding of hospital coding and billing rules * Clinical and critical thinking skills to evaluate appropriate coding * Strong organization skills with attention to detail * Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships. * Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Base Salary Range $95,000.00 - $127,000.00 At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role. Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************. Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and billing, analyzing inpatient DRG claims based on industry standard inpatient coding guidelines, and supporting the Office of the Chief Medical Officer in managing disputes related to clinical claim reviews. This position is a production-based role with production and quality metric goals. What you'll do: * Review provider disputes for DRG Coding and Clinical Validation (MS and APR) * Review and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met. * Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures * Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including troubleshooting and review for data accuracy. * Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests. * Create and present education to Expert Claim Review Teams and other departments dispute findings. * Research and analysis of content for DRG reviews. * Use of strong coding and industry knowledge to create and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales * Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities. * Support for client facing teams as needed relating to client inquiries related to provider disputes. * Utilize the most up-to-date approved Zelis medical coding sources for claim review maintenance. * Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends. * Ensure adherence to quality assurance guidelines. * Monitor, research, and summarize trends, coding practices, and regulatory changes. * Actively contribute new ideas and support ad hoc projects, including time-sensitive requests. * Ensure adherence to quality assurance guidelines. * Maintain awareness of and ensure adherence to ZELIS standards regarding privacy. What you'll bring to Zelis: * 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred * Current, active Inpatient Coding Certification required (ie. CCS, CIC,RHIA, RHIT, CPC or equivalent credentialing). * Registered Nurse licensure preferred * Bachelor's Degree Preferred in business, healthcare, or technology preferred. * Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers * Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs * Understanding of hospital coding and billing rules * Clinical skills to evaluate appropriate Medical Record Coding * Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner. * Background and/or understanding of the healthcare industry. * Knowledge of National Medicare and Medicaid regulations. * Knowledge of payer reimbursement policies. * Creative problem-solving skills, leveraging insights and input from other parts of an organization. * Consistently demonstrate ability to act and react swiftly to continuous challenges and changes. * Excellent analytical skills with data and analytics related solutions. * Excellent communication skills. * Strong organization and project/process management skills. * Strong initiative, self-directed and self-motivation. * Good negotiation, problem solving, planning and decision-making skills. * Ability to manage projects simultaneously and achieve goals. * Excellent follow through, attention to detail, and time management skills. Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Base Salary Range $95,000.00 - $127,000.00 At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role. Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************. Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

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 overseeing a team of 4-5 employees that assesses Medicare claims for accuracy, compliance, and eligibility, ensuring that claims are processed efficiently and in accordance with industry standards, regulatory requirements, and organizational policies. This position will guide and support the claims review team, handle escalations, and collaborate with other departments to improve claims processing and ensure timely reimbursements. Essential Functions -Supervise and manage a team of claims reviewers to ensure accurate and timely healthcare claims processing. -Oversee claims review and analysis to ensure compliance with healthcare regulations, payer requirements, and organizational policies. -Resolve escalated or complex claims issues, ensuring appropriate adjudication and dispute resolution. -Monitor team performance, provide feedback, and conduct regular evaluations to support professional growth. -Implement and enforce policies and procedures to streamline the claims review process for greater accuracy and efficiency. -Collaborate with billing, coding, and compliance teams to ensure adherence to regulatory and payer standards. -Analyze claims data to identify trends, address issues, and recommend process improvements. -Provide training, guidance, and ongoing education for new and existing team members on industry changes and standards. Qualifications Education Bachelor's Degree required (experience can be substituted in lieu of degree) Experience At least 3-5 years of experience in healthcare claims review or processing required At least 1-2 years of experience in a senior or leadership role required Medicare Advantage claims experience is highly preferred QNXT experience is highly preferred Knowledge, Skills, and Abilities Strong knowledge of healthcare claims processes, coding (CPT, ICD-10), and payer regulations. Excellent leadership, communication, and problem-solving skills. Proficiency in claims processing software and healthcare management systems. Strong attention to detail and the ability to manage multiple tasks and priorities. 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 $78,000.00 - $113,453.60/Annual Grade 7 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: 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.

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. This role is supervising a team of roughly 5 Medicaid Claims Reviewers. The role is claims inventory management, identifying ACO claims adjudication errors, doing high-dollar reviews, noting claims denial trends, coaching/mentoring team members, and participating in the development of departmental desktop procedures. The ideal candidate has a strong background in Medicaid/ACO claims processing and is a Certified Coder who can understand the difference in different claims edits. Job Summary Responsible for overseeing a team that assesses healthcare claims for accuracy, compliance, and eligibility, ensuring that claims are processed efficiently and in accordance with industry standards, regulatory requirements, and organizational policies. This position will guide and support the claims review team, handle escalations, and collaborate with other departments to improve claims processing and ensure timely reimbursements. Essential Functions -Supervise and manage a team of claims reviewers to ensure accurate and timely healthcare claims processing -Oversee claims review and analysis to ensure compliance with healthcare regulations, payer requirements, and organizational policies -Resolve escalated or complex claims issues, ensuring appropriate adjudication and dispute resolution -Monitor team performance, provide feedback, and conduct regular evaluations to support professional growth -Implement and enforce policies and procedures to streamline the claims review process for greater accuracy and efficiency -Collaborate with billing, coding, and compliance teams to ensure adherence to regulatory and payer standards -Analyze claims data to identify trends, address issues, and recommend process improvements -Provide training, guidance, and ongoing education for new and existing team members on industry changes and standards -Performs other duties as assigned -Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records. -Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks. -Identify underpayments, overpayments, and potential billing errors. -Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures. -Stay updated on insurance company policies, billing guidelines, and reimbursement rules. Qualifications Education Bachelor's degree required (experience can be considered in lieu of degree) License Certified Professional Coder (CPC) preferred Experience At least 3-5 years of experience in healthcare claims review or processing required At least 1-2 years of experience in a senior or leadership role required Knowledge, Skills, and Abilities Strong knowledge of healthcare claims processes, coding (CPT, ICD-10), and payer regulations Excellent leadership, communication, and problem-solving skills Proficiency in claims processing software and healthcare management systems Strong attention to detail and the ability to manage multiple tasks and priorities Additional Job Details (if applicable) Working Conditions This is a full-time role with a Monday through Friday, 8:30-5 schedule This is a remote role that can be done from most US states Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $78,000.00 - $113,453.60/Annual Grade 7 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.

In our time of Company growth, we are seeking employment for all open positions: Clinical and Customer Service positions Registered Nurse/Charge Nurse RNs RN (Charge Nurse) LPN's LPNs Pediatric (Bilingual) LPNs OBGYN (Bilingual) MA's Scheduling Coordinator DME Specialist Surgical Tech Clinical Continuous Improvement Specialist/LPNs/MAs Patient Service Representative Technical Support Level II Help Desk Technician EHR Specialist/RNs/LPNs Dental Assistant Pharmacy Technician (Float) Staff Pharmacist (Float) Environmental Service Technician/Float Work Location: Bradenton, FL Walk-in Interviews Every Tuesday Location: Corporate Headquarters: 101 Riverfront Blvd. Bradenton, Florida 34205 Date: Every Tuesday Time: 9 am - 1 pm. Please bring your resume to the Hiring Event and dress professionally Benefits offered by MCR Health * Monday through Friday schedule; "No Late Nights" or Weekends (except for our 3 clinical sites with pharmacies, which are open until 8 pm). * Student Loan Forgiveness is also offered to MCR Health employees. * Medical, Dental, and Vision * PTO and Sick time Requirements vary by position. View open nursing positions and requirements on our Staff Careers page at mcr.health!

In our time of Company growth, we are seeking employment for all open positions: Registered Nurse/Charge Nurse RNs RN (Charge Nurse) LPN's LPNs Pediatric (Bilingual) LPNs OBGYN (Bilingual) MA's Scheduling Coordinator DME Specialist Surgical Tech Clinical Continuous Improvement Specialist/LPNs/MAs Patient Service Representative Technical Support Level II Help Desk Technician EHR Specialist/RNs/LPNs Dental Assistant Pharmacy Technician (Float) Staff Pharmacist (Float) Environmental Service Technician/Float Work Location: Bradenton, FL Hiring Event Location: Corporate Headquarters: 101 Riverfront Blvd. Bradenton, Florida 34205 Date: Tuesday, December 16, 2025 Time: 9 am - 1 pm. Please bring your resume to the Hiring Event and dress professionally Benefits offered by MCR Health * Monday through Friday schedule; "No Late Nights" or Weekends (except for our 3 clinical sites with pharmacies, which are open until 8 pm). * Student Loan Forgiveness is also offered to MCR Health employees. * Medical, Dental, and Vision * PTO and Sick time Job requirements vary by position. Please view open nursing positions and non-nursing positions on our Staff Careers page at mcr. health!

Care Dimensions has a truly meaningful purpose - to provide compassionate care to our patients who are faced with an advanced or end-of-life illness. Since 1978, Care Dimensions has been a driving force in expanding access to hospice and palliative care in Massachusetts. At Care Dimensions, we invest in people who take pride in caring and supporting. We support and strengthen our people with extensive training, teamwork and technology. Our values are embedded in our work, each and every day: Compassion, Excellence, Collaboration, Integrity, Responsiveness, Innovation. As part of the Care Dimensions team, you'll gain the support and inspiration for a career you'll find meaningful every day. Walk-In-Hiring! We would love to speak with you! It is easy; just call us between 9 a.m. - 5 p.m.at ************ to speak with a member of the Care Dimensions HR team one-on-one. You can also email us at *********************** Care Dimensions is the largest not-for-profit hospice in Massachusetts, serving more than 90 communities. We have full-time, part-time, evening/night and weekend positions available (clinical and non-clinical), serving both the North Shore and Greater Boston/Metro-West areas . If you are mission driven and want to work for New England's premier not-for-profit hospice, we invite you to apply. Types of positions that may be available are: - Registered Nurse (RN) and Licensed Practical Nurse (LPN) - Hospice Aide (Certified Nursing Assistant) CNA license is required - Clinical Manager - Social Worker - Spiritual Counselor - Nurse Practitioner - Administrative Assistant Benefits are offered to employees that are scheduled to work 20+ hours/week, which include a generous earned time (vacation days) program, tuition reimbursement, scholarship programs, student loan paydown program, two retirement plans, in addition to medical/dental/vision/life/disability insurance, and so much more! Care Dimensions is an Equal Opportunity Employer. We are committed to building a team that represents a variety of backgrounds, perspectives, and skills. Applicants needing a reasonable accommodation during any part of the interview process may request one.