Leader jobs at Tenet Healthcare - 31 jobs

Patient Account Lead Representative - Remote
Tenet Healthcare Corporation 4.5
Leader job at Tenet Healthcare
Responsible for providing assistance, coaching and training to staff members, including new hires. They support and assist the Team, the Supervisor and Management with complex inventory and issue resolution. Responsible for all aspects of the billing, follow up and collection activity for payers that are Supplemental to Medicare. May maintain a large dollar inventory desk or complex accounts as well as serve as just-in-time staffing, working inventory for team members that may be absent or backlogged. May assist in special projects as assigned my management, including acting as a point of contact for internal operational questions. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. * Responsible for all aspects of insurance follow up and collections, including making telephone calls, accessing payer websites. May maintain a large dollar inventory desk as well as serve as just-in-time staffing, working inventory for team members that may be absent or backlogged. Effectively resolve complex or aged inventory, including payment research, payment recoups with minimal or no assistance necessary. Accurately and thoroughly document the pertinent collection activity performed. Review the account information and necessary system applications to determine the next appropriate work activity. Verify claims adjudication utilizing appropriate resources and applications. Initiate telephone or letter contact to patients to obtain additional information as needed. Perform appropriate billing functions, including manual re-bills as well as electronic submission to payers. Edit claims to meet and satisfy billing compliance guidelines for electronic submission. Manage and maintain desk inventory, complete reports, and resolve high priority and aged inventory. Proactively identify issues or trending and provide suggestions for resolution. * Provide assistance, coaching and training to staff members, including new hires. Provide enhanced training and assist staff with techniques to increase production, quality and collections. Participate in the new hire peer interviewing process. Assist in special projects assigned by management. * Participate and attend meetings, training seminars and in-services to develop job knowledge. Attend various conference calls, webinars or advanced training to provide assistance to the team members. Respond timely to emails and telephone messages from the staff, management and the client. Effectively communicate issues to management, including payer, system or escalated account issues as well as develop solutions. FINANCIAL RESPONSIBILITY (specify Revenue/Budget/Expense): $2.5 million R&D Budget KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Very good written and verbal communication skills * Strong interpersonal skills * Advanced technical skills including PC and MS Outlook * Advanced knowledge of UB-04 and Explanation of Benefits (EOB) interpretation * Advanced knowledge of CPT and ICD-9 codes * Advanced knowledge of insurance billing, collections and insurance terminology Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience preferred to perform the job. * High school diploma or equivalent education * 3-6 years experience in Medical/Hospital Insurance related collections PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Office/Teamwork Environment As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step! Compensation and Benefit Information Compensation * Pay: $20.51 - $30.77 per hour. Compensation depends on location, qualifications, and experience. * Position may be eligible for a signing bonus for qualified new hires, subject to employment status. * Conifer observed holidays receive time and a half. Benefits Conifer offers the following benefits, subject to employment status: * Medical, dental, vision, disability, and life insurance * Paid time off (vacation & sick leave) - min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked. * 401k with up to 6% employer match * 10 paid holidays per year * Health savings accounts, healthcare & dependent flexible spending accounts * Employee Assistance program, Employee discount program * Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance. * For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act. Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: ***************************** The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. **********
$20.5-30.8 hourly 6d ago

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Lead, Risk Adjustment - Predictive Analytics
Molina Healthcare Inc. 4.4
Columbus, OH jobs
The Lead, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina's Prospective and Retrospective Interventions. Provides technical, functional and business training to other team members to enable them to perform the tasks required. Knowledge/Skills/Abilities * Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions. * Design and development ad-hoc as well as automated analytical modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP. * Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses. * Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost. * Conduct root cause analysis for business data issues, report to leadership the summary of findings and resolutions. * Design and lead development of tracking system for risk scores for all intervention outcome and for overall markets and LOB. * Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis. * Work directly with interdepartmental / intradepartmental stakeholders along with Molina Executives to establish/deliver/explain the business requirement as well as data/data points and do necessary escalation as required. * Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors. * Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations. * Act as a subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics and provide training as required. Stay current with industry regulation changes and educate the team and management as necessary. * Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytics reporting modules to ensure no impact to the end users. * Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus. * Develop training modules to help analysts understand processes, solutions or designs to meet the customer request for new/existing staff. * Provide technical, functional and business training to other team members to enable them to perform the tasks required. * Maintain a team culture to adopt fast faced agile environment and foster a positive attitude to take on challenging and time sensitive projects. * Take accountability of tasks and projects assigned. Job Qualifications Required Education Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline. Required Experience * 6+ Years of experience in working with data mapping, scrubbing, scrapping, and cleaning of data. * 5+ Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design * 5+ years of experience in working with Microsoft T-SQL, SSIS and SSRS. * Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage. * 5+ Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP. * 5+ Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting. * 5+ Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics. * 5+ Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions PHYSICAL DEMANDS Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $80,412 - $188,164 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$80.4k-188.2k yearly 20d ago
Claims Operations Lead
HCA Healthcare 4.5
Nashville, TN jobs
*** This role prefers candidates local to California and/or Pacific Time Zone*** Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a Claims Operations Lead today with Work from Home. **Benefits** Work from Home offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. + Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. + Free counseling services and resources for emotional, physical and financial wellbeing + 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) + Employee Stock Purchase Plan with 10% off HCA Healthcare stock + Family support through fertility and family building benefits with Progyny and adoption assistance. + Referral services for child, elder and pet care, home and auto repair, event planning and more + Consumer discounts through Abenity and Consumer Discounts + Retirement readiness, rollover assistance services and preferred banking partnerships + Education assistance (tuition, student loan, certification support, dependent scholarships) + Colleague recognition program + Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) + Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits (********************************************************************** **_Note: Eligibility for benefits may vary by location._** Come join our team as a Claims Operations Lead. We care for our community! Just last year, HCA Healthcare and our colleagues donated $13.8 million dollars to charitable organizations. Apply Today! **Job Summary and Qualifications** The **Claims Operations Lead** position's primary function is to support the unit in work distribution and accurate adjudication of claims. In addition, the position is responsible for training and providing direction to Claims Examiners and Audit Research personnel. **DUTIES INCLUDE BUT NOT LIMITED TO:** Adjudicates and distributes work assignments including complex claims, resolving all system edits and audits for hard copy and electronic claims in accordance with policy. Works directly with Health Plans and external vendors to resolve claims issues. Coordinates necessary workflows for verification of referral and payment on non- participating provider claims. Resolves provider and eligibility issues relating to received claims. Processes high dollar claims in accordance with procedures. Identifies potential system programming issues and assists with resolution. Performs any necessary system testing for implementation of new processes within the -400. Provides technical support and training for claims processors and claims examiners. Provides staff with any and all internal communications regarding workflows/changes. Recognizes and appropriately routes claims for carved out services according to health plan contracts. Understands health plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans and capitation arrangements and processes claims using this knowledge. Understands general ledger accounts and posting of claims information to the appropriate accounts. Generates daily reports, assigns work, maintains weekly on hand reports Monitors performance and claims processing times to ensure compliance with performance standards. Perform other duties as assigned **KNOWLEDGE, SKILLS AND ABILITIES: This position requires the following minimum requirements:** Ability to communicate well with supervisors and co-workers. Knowledge of medical terminology. Knowledge of Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS) requirements. Knowledge of ICD-9, ICD-10, CPT, HCPCS, and revenue coding. Ability to analyze claim issues and "trouble shoot" claims problems. Ability to act as a resource and/or trainer for claims processors and claims examiners. Technical competence with claims processing software. Supervisory skills in claims processing. Ability to work in a high volume, production-oriented environment. Detail oriented with an ability to sit for extended periods of time. Ability to work under demanding performance standards for production and quality. Ability to understand, implement and train complex claim procedures. **EDUCATION:** High school diploma or equivalent. **EXPERIENCE:** Three years of experience processing claims, with at least two years of claims examiner experience. Physician Services Group (*********************************************************** is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration, and graduate medical education. We lead more than 1,300 physician practices and 170+ urgent care centers. We are HCA Healthcare's graduate medical education leader. We provide direction for over 260 exceptional resident and fellowship programs. We focus on carrying out value-added solutions. These solutions help physicians deliver patient-centered healthcare. We support HCA Healthcare's commitment to the care and improvement of human life. HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Claims Operations Lead opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. **Unlock the possibilities and apply today!** We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
$74k-96k yearly est. 41d ago
Claims Operations Lead
HCA 4.5
Nashville, TN jobs
* This role prefers candidates local to California and/or Pacific Time Zone* Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a Claims Operations Lead today with Work from Home. Benefits Work from Home offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: * Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. * Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. * Free counseling services and resources for emotional, physical and financial wellbeing * 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) * Employee Stock Purchase Plan with 10% off HCA Healthcare stock * Family support through fertility and family building benefits with Progyny and adoption assistance. * Referral services for child, elder and pet care, home and auto repair, event planning and more * Consumer discounts through Abenity and Consumer Discounts * Retirement readiness, rollover assistance services and preferred banking partnerships * Education assistance (tuition, student loan, certification support, dependent scholarships) * Colleague recognition program * Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) * Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. Come join our team as a Claims Operations Lead. We care for our community! Just last year, HCA Healthcare and our colleagues donated 13.8 million dollars to charitable organizations. Apply Today! Job Summary and Qualifications The Claims Operations Lead position's primary function is to support the unit in work distribution and accurate adjudication of claims. In addition, the position is responsible for training and providing direction to Claims Examiners and Audit Research personnel. DUTIES INCLUDE BUT NOT LIMITED TO: Adjudicates and distributes work assignments including complex claims, resolving all system edits and audits for hard copy and electronic claims in accordance with policy. Works directly with Health Plans and external vendors to resolve claims issues. Coordinates necessary workflows for verification of referral and payment on non- participating provider claims. Resolves provider and eligibility issues relating to received claims. Processes high dollar claims in accordance with procedures. Identifies potential system programming issues and assists with resolution. Performs any necessary system testing for implementation of new processes within the -400. Provides technical support and training for claims processors and claims examiners. Provides staff with any and all internal communications regarding workflows/changes. Recognizes and appropriately routes claims for carved out services according to health plan contracts. Understands health plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans and capitation arrangements and processes claims using this knowledge. Understands general ledger accounts and posting of claims information to the appropriate accounts. Generates daily reports, assigns work, maintains weekly on hand reports Monitors performance and claims processing times to ensure compliance with performance standards. Perform other duties as assigned KNOWLEDGE, SKILLS AND ABILITIES: This position requires the following minimum requirements: Ability to communicate well with supervisors and co-workers. Knowledge of medical terminology. Knowledge of Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS) requirements. Knowledge of ICD-9, ICD-10, CPT, HCPCS, and revenue coding. Ability to analyze claim issues and "trouble shoot" claims problems. Ability to act as a resource and/or trainer for claims processors and claims examiners. Technical competence with claims processing software. Supervisory skills in claims processing. Ability to work in a high volume, production-oriented environment. Detail oriented with an ability to sit for extended periods of time. Ability to work under demanding performance standards for production and quality. Ability to understand, implement and train complex claim procedures. EDUCATION: High school diploma or equivalent. EXPERIENCE: Three years of experience processing claims, with at least two years of claims examiner experience. Physician Services Group is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration, and graduate medical education. We lead more than 1,300 physician practices and 170+ urgent care centers. We are HCA Healthcare's graduate medical education leader. We provide direction for over 260 exceptional resident and fellowship programs. We focus on carrying out value-added solutions. These solutions help physicians deliver patient-centered healthcare. We support HCA Healthcares commitment to the care and improvement of human life. HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "The great hospitals will always put the patient and the patients family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Claims Operations Lead opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
$74k-96k yearly est. 13d ago
Lead, Risk Adjustment - Predictive Analytics
Molina Healthcare 4.4
Cleveland, OH jobs
The Lead, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina's Prospective and Retrospective Interventions. Provides technical, functional and business training to other team members to enable them to perform the tasks required. **Knowledge/Skills/Abilities** + Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions. + Design and development ad-hoc as well as automated analytical modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP. + Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses. + Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost. + Conduct root cause analysis for business data issues, report to leadership the summary of findings and resolutions. + Design and lead development of tracking system for risk scores for all intervention outcome and for overall markets and LOB. + Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis. + Work directly with interdepartmental / intradepartmental stakeholders along with Molina Executives to establish/deliver/explain the business requirement as well as data/data points and do necessary escalation as required. + Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors. + Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations. + Act as a subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics and provide training as required. Stay current with industry regulation changes and educate the team and management as necessary. + Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytics reporting modules to ensure no impact to the end users. + Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus. + Develop training modules to help analysts understand processes, solutions or designs to meet the customer request for new/existing staff. + Provide technical, functional and business training to other team members to enable them to perform the tasks required. + Maintain a team culture to adopt fast faced agile environment and foster a positive attitude to take on challenging and time sensitive projects. + Take accountability of tasks and projects assigned. **Job Qualifications** **Required Education** Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline. **Required Experience** + 6+ Years of experience in working with data mapping, scrubbing, scrapping, and cleaning of data. + 5+ Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design + 5+ years of experience in working with Microsoft T-SQL, SSIS and SSRS. + Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage. + 5+ Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP. + 5+ Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting. + 5+ Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics. + 5+ Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions **PHYSICAL DEMANDS** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $80,412 - $188,164 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$80.4k-188.2k yearly 19d ago
Lead, Risk Adjustment - Predictive Analytics
Molina Healthcare Inc. 4.4
Dayton, OH jobs
The Lead, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina's Prospective and Retrospective Interventions. Provides technical, functional and business training to other team members to enable them to perform the tasks required. Knowledge/Skills/Abilities * Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions. * Design and development ad-hoc as well as automated analytical modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP. * Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses. * Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost. * Conduct root cause analysis for business data issues, report to leadership the summary of findings and resolutions. * Design and lead development of tracking system for risk scores for all intervention outcome and for overall markets and LOB. * Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis. * Work directly with interdepartmental / intradepartmental stakeholders along with Molina Executives to establish/deliver/explain the business requirement as well as data/data points and do necessary escalation as required. * Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors. * Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations. * Act as a subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics and provide training as required. Stay current with industry regulation changes and educate the team and management as necessary. * Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytics reporting modules to ensure no impact to the end users. * Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus. * Develop training modules to help analysts understand processes, solutions or designs to meet the customer request for new/existing staff. * Provide technical, functional and business training to other team members to enable them to perform the tasks required. * Maintain a team culture to adopt fast faced agile environment and foster a positive attitude to take on challenging and time sensitive projects. * Take accountability of tasks and projects assigned. Job Qualifications Required Education Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline. Required Experience * 6+ Years of experience in working with data mapping, scrubbing, scrapping, and cleaning of data. * 5+ Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design * 5+ years of experience in working with Microsoft T-SQL, SSIS and SSRS. * Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage. * 5+ Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP. * 5+ Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting. * 5+ Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics. * 5+ Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions PHYSICAL DEMANDS Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $80,412 - $188,164 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$80.4k-188.2k yearly 20d ago
Cryptographic Governance Lead
Centene 4.5
Remote
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Leads the Cryptographic Governance Program within Enterprise Privacy and Security Risk Management (EPSRM). Provides subject matter expertise to IT and Cybersecurity capability owners who are responsible for implementing the solutions. Works with capability owners, ensuring that cryptographic controls are effectively implemented to protect sensitive data and ensure compliance with regulatory and contractual obligations. Design, implement and operationalize the Cryptographic Governance Program, including identifying any staffing needs. Analyze monitoring and assessments to identify weaknesses and vulnerabilities; collaborate with capability owners to address root causes. Develop and maintain cryptographic policies and standards aligned with industry and regulatory requirements (e.g., encryption, key lifecycle management, certificate management, etc.). Define and track KPI's and metrics to assess risk and maturity; communicate findings to leadership and stakeholders. Monitor industry trends and regulatory changes; communicate relevant developments to internal stakeholders. Identify emerging and deprecated cryptographic algorithms, coordinate transition planning with impacted teams. Maintain expertise in relevant frameworks and standards (e.g. NIST 800-53, FIPS 140). Ensure timely remediation of identified weaknesses; assist in removing blockers as needed. Document and maintain governance processes and procedures. Develop and promote an enterprise cryptographic strategy and use cases for both on-premises and cloud environments. Collaborate with capability owners (e.g., security engineering, operations, IT infrastructure, application teams (to ensure solutions meet internal standards. Provide guidance on cryptographic techniques such as hashing, key combinations, and digital signatures to ensure data confidentiality and integrity. Define requirements for encryption tools and platforms (e.g., AWS KMS, Azure Key Vault, HSMs, and TLS infrastructure). Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Bachelor's Degree Cybersecurity, Mathematics, Cryptography or related field required Master's Degree Cybersecurity, Mathematics, Cryptography or related field preferred 5+ years Cryptographic governance or related cybersecurity roles required Deep understanding of cryptographic algorithms, standards, and protocols (e.g., AES, RSA, TLS) required Proven experience with PKI, key lifecycle management, and encryption across cloud, on-prem, and hybrid environments required Knowledge of data security platforms such as Splunk, Varonis, and the Thales suite of tools required Experience in large, complex organizations and/or healthcare preferred Licenses/Certifications: CISSP Certified Information Systems Security Professional preferred Certified Security Software Lifecycle Professional preferred Certified Cloud Security Professional preferred Pay Range: $107,700.00 - $199,300.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
$107.7k-199.3k yearly Auto-Apply 15d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Columbus, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Columbus, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago
Commercial Lending Team Lead - Loan Accounting - Remote
Unitedhealth Group 4.6
Draper, UT jobs
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together.** You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week. **Primary Responsibilities:** + Lead and manage a team of loan analysts, providing guidance, training, and support as needed + Oversee the day-to-day operations of the loan accounting team, ensuring that loan transactions are processed accurately and in a timely manner + Oversee the process flow to guarantee timely funding of all loans assigned to the loan accounting team + Collaborate with internal stakeholders, such as Compliance, Risk Management, and Finance departments, to ensure compliance with regulatory requirements and internal policies + Develop and implement policies and procedures to improve efficiency and accuracy in loan accounting processes + Perform regular reviews of loan accounting transactions to identify discrepancies or errors and take corrective actions as needed + Perform periodic review of loan system data integrity, review of critical coding (LTV, Risk Codes, Collateral Codes, Credit line codes etc.) + Performs periodic system maintenance to global rate indexes + Prepare reports and analysis on loan accounting activities for management review + Participate in audits and regulatory examinations related to loan accounting processes + Keep abreast of industry trends and best practices in loan accounting to recommend and implement process improvements + Spearhead/assign new projects to incorporate innovation and minimize risk through compliance and accuracy + Provide requirements while leading testing and implementation for new/current systems to enhance productivity and timeliness + Other duties as assigned You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + 5+ years of commercial lending operations experience in loan accounting, with 2+ years in a supervisory or team lead role + 2+ years of experience working in banking or another financial institution + Experience with loan and lease documentation, including UCC filings + In-depth knowledge of loan accounting principles, practices, and regulations + Proficiency in Microsoft Office Suite and other accounting software + Proven solid analytical skills and attention to detail + Proven excellent written and verbal communication and interpersonal skills + Proven growth mindset with the ability to build out new departments and processes + Demonstrated ability to lead and motivate a team in a fast-paced and dynamic environment + Must be able to travel 10% **Preferred Qualifications:** + Healthcare Industry experience + Experience of Commercial & Consumer Loan Operations + Experience with SQL or Power BI + Knowledge of standard commercial loan and lease documentation requirements for various commercial loan types (Real Estate, SBA, and Asset Based loans) + Familiarity with Commercial & Consumer lending regulatory and compliance components + Knowledge of the necessary documentation and procedures to secure and perfect the bank's collateral *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $89,900 to $160,600 annually based on full-time employment. We comply with all minimum wage laws as applicable. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._
$41k-60k yearly est. 30d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Cleveland, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Cleveland, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Akron, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Cincinnati, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Akron, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Cincinnati, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Dayton, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Dayton, OH jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare 4.4
Ohio jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. - Trains new employees and provides guidance to others with respect to complex appeals and grievances. - Researches and resolves escalated issues including state complaints and high visible complex cases. - In conjunction with claims leadership, assigns claims work to team. - Prepares appeal summaries and correspondence, and documents information for tracking/trending data. - Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. - Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits, and review of covered services. - Contacts members/providers via written and verbal communications as needed. - Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. - Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Strong customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.7-46.4 hourly 5d ago
Lead Specialist, Appeals & Grievances
Molina Healthcare Inc. 4.4
Ohio jobs
Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties * Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. * Trains new employees and provides guidance to others with respect to complex appeals and grievances. * Researches and resolves escalated issues including state complaints and high visible complex cases. * In conjunction with claims leadership, assigns claims work to team. * Prepares appeal summaries and correspondence, and documents information for tracking/trending data. * Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. * Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. * Meets claims production standards set by the department. * Applies contract language, benefits, and review of covered services. * Contacts members/providers via written and verbal communications as needed. * Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. * Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. * Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. * Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications * At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. * Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. * Strong customer service experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. * Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.7-46.4 hourly 6d ago