<h3>Job Description</h3>
Job Description
Let’s do great things, together!
About Moda Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.
 Position Summary Responsible for benefit configuration and administration for all new and renewing Medical or Dental groups, with a focus on standard and plans of low to moderate complexity, including table update projects, achieving the highest possible auto-adjudication rates, while at the same time maintaining excellent quality. Maintain Enterprise Benefit Tracker (EBT) notes groups as needed to provide additional clarity to internal and external users regarding benefit specifics. Analyzes system solutions, defines and builds benefit designs, and maintains configuration within the systems. This is a FT WFH role. Pay Range $25.08 - $41.28 hourly, depending on experience. *Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.
 Please fill out an application on our company page, linked below, to be considered for this position.
<a href="https://j.brt.mv/jb.do?reqGK=27750493&amp;refresh=true" target="_blank">https://j.brt.mv/jb.do?reqGK=27750493&amp;refresh=true</a> Benefits:
<ul>
<li>Medical, Dental, Vision, Pharmacy, Life, &amp; Disability</li>
<li>401K- Matching</li>
<li>FSA</li>
<li>Employee Assistance Program</li>
<li>PTO and Company Paid Holidays</li>
</ul>
 Required Skills, Experience &amp; Education:
<ul>
<li>Bachelor’s degree or equivalent work experience.</li>
<li>1 - 3 years prior Healthcare/Insurance experience is required, with a preference for those with experience building benefits in Facets or other systems.</li>
<li>Knowledge of existing claims procedures, which may be demonstrated by 1-2 years as Lead Claims Processor, Claims Auditor, Customer Service Representative, or other related position in the insurance industry. Consistently exceeding all levels of performance or equivalent experience.</li>
<li>Ability to gather business requirements for specialized groups or projects.</li>
<li>Ability to analyze and recognize potential business impacts for impacted departments regarding benefit and/or contract changes and to offer probable solutions or alternatives.</li>
<li>PC proficient with good working knowledge of Microsoft Word and Excel.</li>
<li>Strong system knowledge of Facets and Enterprise Benefit Tracker, or equivalent Health Insurance benefits systems.</li>
<li>Ability to communicate effectively, both orally and in writing with users, systems personnel, vendors, clients and management.</li>
<li>Ability to correctly interpret contracts, coupled with state and federal laws and limitations, and to convert into Facets benefit configuration.</li>
<li>Ability to plan, organize and prioritize task assignments to ensure established guidelines, timelines and quality goals are met.</li>
<li>Ability to document business processes.</li>
<li>Ability to come into work on time and on a daily basis; work additional hours as needed.</li>
<li>Ability to work independently, with minimal supervision.</li>
<li>Maintain confidentiality and project a professional business image.</li>
</ul>
 Primary Functions:
<ul>
<li>Creates and maintains Facets benefit components and configures standard products or those of moderate complexity for new and renewing Medical or Dental groups as well as updating and maintaining EBT. Products that are of higher complexity may be assigned but will be expected to require assistance from others on the team.</li>
<li>Participates in meetings representing Benefit Configuration Administration to fully understand plan benefits and validate Facets capabilities.</li>
<li>Ensures benefit configuration turnaround times are met for all new and renewing groups.</li>
<li>Answers inquiries from Medical or Dental claims departments, Underwriting, Marketing, Professional Relations and Business Implementation Unit regarding contract and product set-up issues on medical or Dental group business.</li>
<li>Performs quality audits on benefit configuration at the direction of department management.</li>
<li>Performs quality assurance testing on test claims to validate benefit configuration will meet the needs of the Medical or Dental Claims departments.</li>
<li>Evaluates and resolves benefit configuration questions via WorkFlow claims inquiries.</li>
<li>Communicates product updates and changes to the Claims departments, Marketing and Contracts via e-mail, inter office mail or EBT updates.</li>
<li>Assists with department projects and reports at the direction of department management</li>
<li>Interprets benefit information from the group application and or contract language in order to create a product within corporate turnaround time standards.</li>
<li>Problem solves, by thinking “outside the box” to identify the most efficient use of the system’s capability from a corporate perspective.</li>
<li>Identifies situation where benefit configuration alone cannot fully meet the plan’s requirements. Works with departmental management, and cross functionally, to identify the Workflow configuration and associated business processes needed.</li>
<li>Documents departmental policies and business processes as assigned by department management.</li>
<li>Performs other duties as assigned</li>
</ul>
 Working Conditions &amp; Contact with Others
<ul>
<li>Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need during peak business times.</li>
<li>Inside the company with Medical or Dental Claims and Customer Service, Professional Relations, Marketing, Contracts, Business Implementation, Membership Accounting, IT, Actuarial, Underwriting, and Health Care Services.</li>
</ul>
Together, we can be more. We can be better. Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. For more information regarding accommodations, please direct your questions to Kristy Nehler &amp; Danielle Baker via our <a href="mailto:humanresources@modahealth.com" target="_blank">humanresources@modahealth.com</a> email.

Benefit Config Analyst I, II, or III (DOE)

<h3>Job Description</h3>
Job DescriptionBenefits: 
<ul>
<li>Opportunity for professional growth</li>
<li>401(k)</li>
<li>Competitive salary</li>
<li>Dental insurance</li>
<li>Health insurance</li>
<li>Paid time off</li>
<li>Vision insurance</li>
</ul>
 Job Title: Medical Clerk EDD Claims Processor Location: Allied Health Solutions Medical Group, Inglewood, CA Job Type: Full-Time Department: Administrative Allied Health Solutions Medical Group, an outpatient medical clinic providing primary care services to patients, is seeking a Medical Clerk-EDD Claims Processor.The successful candidatewill be responsible for providing administrative services under the supervision of management. The clinic is located in Inglewood, California. This is a full-time position from Monday to Friday, 8:30am to 5:00pm. Position Summary The Medical Clerk EDD Claims Processor is responsible for completing and managing all aspects of EDD-related paperwork and communications. This position plays a key role in ensuring timely and accurate submission of medical documentation required for disability leave claims, while maintaining strict confidentiality and compliance with clinic policies and healthcare regulations. Key Responsibilities 
<ul>
<li>Process and complete EDD disability leave claim forms accurately and efficiently.</li>
<li>Liaise with healthcare providers to obtain necessary medical information and signatures.</li>
<li>Communicate with patients regarding claim status and required documentation.</li>
<li>Submit claims electronically or by mail in accordance with EDD guidelines.</li>
<li>Ensure timely processing of patient check out documents</li>
<li>Maintain organized records of all submitted claims and correspondence.</li>
<li>Respond to phone inquiries from patients, providers, and EDD representatives in a timely and professional manner.</li>
<li>Review and follow up on patients HIPAA compliant emails and text messages</li>
<li>Ensure compliance with HIPAA and all relevant state and federal privacy regulations.</li>
<li>Assist with other front office or administrative tasks as needed, including scheduling, patient check-in/check-out, and records management.</li>
<li>Basic knowledge of ICD-10 codes</li>
<li>Review and follow up on patients HIPAA compliant emails and text messages.</li>
</ul>
Qualifications 
<ul>
<li>Associate degree or higher qualifications in healthcare administration or equivalent training is required. Medical billing knowledge is a plus.</li>
<li>12 years of experience in a medical office or healthcare setting preferred.</li>
<li>Familiarity with EDD disability leave forms/processes is strongly preferred.</li>
<li>Excellent organizational and time management skills.</li>
<li>Strong written and verbal communication abilities.</li>
<li>Proficient in Microsoft Office and electronic medical record (EMR) systems.</li>
<li>Ability to handle confidential information with discretion and professionalism.</li>
</ul>
Benefits 
<ul>
<li>Competitive pay</li>
<li>Health, dental, and vision insurance</li>
<li>Paid time off and holidays</li>
<li>Supportive team environment</li>
<li>Opportunities for professional growth</li>
</ul>

Medical Clerk

<h3>Job Description</h3>
Job Description
Business Office Clerk - Accounts Payable and Receivable
This position includes both Accounts Payable and Accounts Receivable and requires a high level of detail. 
Full Time | Days | Monday-Friday | 8am-4:30pm
The Wesley Community is no longer requiring employees to be vaccinated for COVID-19! 
Everything we do at The Wesley Community is guided by our Core Values which form the acronym "CARES". These Core Values are COMPASSION, ACCOUNTABILITY, RESPECT, EXCELLENCE and SPIRIT. It's more than a job: it's caring that starts in the heart.
What will I do as a Business Office Clerk for The Wesley Community?
<ul>
<li>Process checks for corporations for the following purposes: Loan and mortgage payments, equipment payables, supply payables, food payables, and other miscellaneous.</li>
<li>Send checks and maintain a file of paid invoices.</li>
<li>Process and verify payment of invoices on a timely basis.</li>
<li>Attach original invoice to duplicate copy/cancelled check for permanent record.</li>
<li>Communicate with supplier/vendors concerning errors or questions about invoices.</li>
<li>Prepare totals of open invoices, accounts payable, cash disbursements, etc., as may be directed.</li>
<li>Assist in the establishment and maintenance of an adequate accounting system that reflects the operating cost of the facility. </li>
<li>Assist the Purchaser with the establishment and maintenance of vendor files in Microsoft GP. Ensure that all files contain correct W-9, remittance, and discount data. </li>
<li>Prepare monetary transfer between bank accounts, as necessary or as directed by the Controller, Staff Accountant or Chief Financial Officer.</li>
<li>Ensure various departments are properly charged with supplies and equipment they have received for cost allocation purposes.</li>
<li>Code checks with appropriate department numbers to ensure expenses are distributed to the correct department.</li>
<li>Match invoices to packing slips for all corporations and verify pricing.</li>
<li>Request missing packing slips from the Purchaser or other staff that have not been given to the Business Office Clerk to ensure they are properly matched up with invoices.</li>
<li>Maintain current and historical information as requested. This includes but is not limited to: energy bills, agency expenses, Woodlawn apartment replacements, cell phone bills, and special project costs. </li>
<li>Reconcile credit card purchases on a monthly basis and charge expense accounts and facilities as needed. </li>
<li>Assist the Human Resources Staff with issuance of payroll payables.</li>
<li>Maintain all Education Reimbursement records.</li>
<li>Reconcile monthly therapy contracted services invoices to billing system.</li>
<li>Assist Billing Specialists with preparation of data for billing long-term care insurance companies for services rendered to residents.</li>
<li>Perform monthly billing and prepare monthly private pay invoices for phone, cable and internet charges for Embury Apartments.</li>
<li>Process insurance denials in Waystar.</li>
<li>Follow up on outstanding long-term care insurance claims and requests, as needed.</li>
<li>Perform bi-weekly billing for Wesley Senior Solutions.</li>
<li>Process mail and correspondence pertaining to your position. Sort and distribute incoming mail on a timely basis. </li>
<li>Make recommendations to the Controller or RFSM about office operations and accounting procedures.</li>
<li>Assist in standardizing the methods in which work will be accomplished. </li>
<li>Maintain Accounts Payable and Business Office related files.</li>
<li>Utilize computer reports and output. </li>
<li>Assist in preparing financial and statistical reports as directed.</li>
<li>Assist in preparing and making changes in our accounting system as necessary or directed.</li>
<li>Perform functions of computer/data processor as necessary.</li>
<li>Perform general secretarial/clerical duties including but not limited to typing, filing, faxing, and word processing as necessary or directed.</li>
<li>Answer office phones; refer callers to appropriate person.</li>
<li>Respond to residents, employees, families, visitors, etc. in a friendly and courteous manner.</li>
<li>Assist the Controller and RFSM with audits for all corporations.</li>
<li>Post general ledger information for all corporations.</li>
<li>Perform general, administrative duties as specifically assigned by the Controller and RFSM.</li>
<li>Other work assigned by Controller, RSFM or that become necessary.</li>
</ul>
 
Business Office Clerk Requirements:
<ul>
<li>High School Diploma or equivalency.</li>
<li>A minimum of two years' experience in a business setting.</li>
<li>Accounts Payable experience preferred.</li>
<li>Computer, word processing and Microsoft Excel experience preferred.</li>
<li>Experience in a health care setting preferred.</li>
</ul>
 
The Wesley Community strives to have its employees be part of this culture of excellence, to enjoy their work and be rewarded for their superior efforts and performance.
 
Employee Benefits:
<ul>
<li>Competitive pay rates.</li>
<li>Flexible scheduling options.</li>
<li>Opportunities for professional growth &amp; development.</li>
<li>Caring and supportive teamwork atmosphere.</li>
<li>Healthcare benefits for qualifying employees upon hire.</li>
<li>A fun environment, including theme weeks, recognition events and opportunities for involvement.</li>
</ul>
 
About the Wesley Community:
For over 40 years, The Wesley Community has provided services and programs with a commitment to compassion, caring and excellence. Our distinctive continuum of care offers a unique balance of community living and care giving that ensures quality of life at every stage of life.
We are a mission driven, not-for-profit organization that puts people first. We are proud of our reputation for excellence, innovation, and a personal approach to care and services. We encourage and support our residents in their efforts to achieve their goals, and we treat them respectfully.
Learn more about working at the Wesley Community at our careers page: <a href="http://www.thewesleycommunity.org/careers/" target="_blank">www.thewesleycommunity.org/careers/</a>
Find The Perfect Work-Life Balance as a Health Care Professional in The Scenic Saratoga Region - The Wesley Community

Business Office Clerk

<h3>Job Description</h3>
Job Description
We exist for workers and their employers -- who are the backbone of our economy.&nbsp; That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.
As a Stop Loss Reporting Analyst, the employee will support the Stop Loss Team in managing the monthly reporting for Specific and Aggregate Claims for both internal and external customers. An ideal candidate may have prior experience as a claims processor, with exposure to stop loss terminology and concepts.
Responsibilities Include:
<ul>
<li>
Review Stop Loss contracts or policies to confirm Specific Deductibles, Lasered Claimants, Aggregate Factors, and Attachment Points
</li>
<li>
Ensure timely setup of new and renewing stop loss groups
</li>
<li>
Monitor members nearing or exceeding Specific Deductibles
</li>
<li>
Generate and update Monthly Trigger Reports and Aggregate Reports for internal and external use
</li>
<li>
Create and deliver monthly reports to carriers, including Aggregate Accommodations and Year-End Aggregate Filings
</li>
<li>
Gather supporting documentation from internal departments and external entities
</li>
<li>
Regularly communicate with departments, vendors, clients, and carriers
</li>
<li>
Prepare reports and provide insights and recommendations to leadership
</li>
<li>
Schedule and automate recurring reporting tasks to meet internal and carrier-specific goals
</li>
<li>
Identify and communicate potential issues or errors affecting stakeholders
</li>
<li>
Assist with Stop Loss filings and perform additional duties as needed
</li>
<li>
Navigate systems such as Ringmaster, Javelina, and HRP
</li>
</ul>
Qualifications:
Required Skills and Abilities:
<ul>
<li>
1–3 years of experience in stop loss, excess loss, reinsurance, or a related industry.
</li>
<li>
Strong analytical, problem-solving, and decision-making skills.
</li>
<li>
Proficiency in Excel and comfort with data analysis.
</li>
<li>
Ability to work cross-functionally and communicate effectively across technical and non-technical teams.
</li>
<li>
Fast learner with adaptability to a deadline-driven environment.
</li>
<li>
Excellent written and verbal communication skills.
</li>
</ul>
Work Location:
<ul>
<li>
This position is remote
</li>
</ul>
Centivo Values:
<ul>
<li>
Resilient – This is wicked hard There is no easy button for healthcare affordability Luckily, the mission makes it worth it and sustains us when things are tough Being resilient ensures we don’t give up
</li>
<li>
Uncommon - The status quo stinks so we had to go out and build something better We know the healthcare system It isn't working for members, employers, and providers So we're building it from scratch, from the ground up Our focus is on making things better for them while also improving clinical results - which is bold and uncommon
</li>
<li>
Positive – We care about each other It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it Because of that, we make sure we give kudos freely and feedback with care When our tank gets low, a team member is there to be a source of new energy We celebrate together We are supportive, generous, humble, and positive
</li>
</ul>
Who we are:
Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.
Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase &amp; Co.
Compensation Range: $45K - $52K

Stop Loss Reporting Analyst

<h3>Job Description</h3>
Job Description
Employee Signing Incentive for Regular Full-Time Employees:
Livingston County Community Mental Health Authority is excited to offer an Employee Signing Incentive to eligible new hires. Regular full-time employees will receive $2,000, less applicable taxes. More information on terms and conditions will be made available at the time an offer of employment is made.
About Us:
Livingston County Community Mental Health is a public mental health services provider located in Howell, Michigan, between Detroit and Lansing. We are an agency joined by the shared vision to create a healthy and rewarding life in the community for everyone. Our team approach works together to serve individuals with a wide array of needs in order to create individualized pathways to wellness, resilience, recovery, and self-determination.
Working for Us: (Regular Full-time Only)
Join our team and enjoy a generous benefits package effective on Day 1, including a 5% employer retirement contribution and a voluntary 457(b) salary deferment plan. We provide employer-paid 2X salary life insurance, long-term disability plus generous contributions to BCBS medical and Delta Dental. Find rewarding work supporting Livingston County residents alongside dedicated colleagues.
Our comprehensive benefits plan also includes vision coverage, short-term disability, accident coverage, legal and identity theft programs, and voluntary life insurance. Take advantage of our Spring Health Mental Health Wellness program, offering free counseling, life coaches, and self-care tools. Generous paid time off with vacation, sick, personal, 13 holidays (4 floating), and more choices through our Cafeteria Benefit plan.
We prioritize your overall well-being through robust financial benefits, mental health support, and work-life balance offerings. Become part of our mission while enjoying a valuable total rewards package. All while enjoying rewarding work supporting Livingston County residents alongside dedicated colleagues.
The Provider Claims Processor will look forward to: 
Meaningful, rewarding work with opportunities to develop your expertise in a newly streamlined and innovative finance team. Join a supportive, diverse group that encourages collaboration with experienced colleagues. Our positive environment values diversity and provides avenues to take on special projects aligned with your interests. Enjoy potential for career advancement, plus access to efficient, cutting-edge financial systems that enhance productivity and accuracy.
Role:
At Livingston County Community Mental Health Authority (LCCMHA), we are dedicated to ensuring that mental health providers receive accurate and timely reimbursements for the vital services they provide. To support this mission, we are looking for a Provider Claims Processor to join our team. If you have a keen eye for detail, a knack for problem-solving, and a passion for accuracy in financial and healthcare operations, this could be the perfect role for you. 
In this position, you will be responsible for reviewing and processing provider claims, verifying documentation, and ensuring that payments are accurate and in line with established insurance guidelines. Working closely with internal teams and providers, you will identify and resolve billing discrepancies, audit claims for compliance, and maintain organized financial records. Your expertise in electronic health records and accounting systems will help streamline claims processing while ensuring that all payments are handled efficiently and correctly. 
Beyond processing claims, you will serve as a key point of contact for providers who have questions about billing, reimbursement, or claim statuses. Your ability to communicate effectively will be crucial in resolving issues quickly and maintaining strong provider relationships. Additionally, you will participate in internal meetings, contribute to process improvements, and ensure compliance with HIPAA regulations when handling sensitive information. 
If you're a detail-oriented professional who enjoys working with numbers, problem-solving, and keeping financial operations running smoothly, we'd love to have you on our team. Join LCCMHA and play a vital role in supporting the financial integrity of mental health services in our community. Apply today and be part of something meaningful!
Requirements to join us:
Candidates must be committed to our shared values and commitment to community care, including clinical excellence, community inclusion, community benefit, innovation, integrated care, and improvement. Our collaborative approach to treatment requires strong teaming skills. This is a dynamic, team-oriented position with great opportunities to grow. 
Job Specific Requirements:
Must be proficient in Microsoft Office and willing/able to learn other software as necessary.
High level of integrity and ability to maintain confidentiality of information handled 
Able to effectively collaborate with team members and other program staff.
Ability to work independently and meet deadlines in a fast-paced environment.
Qualifications and Experience: 
Formal training in medical billing procedures and requirements preferred. 
Possession of a high school diploma or its equivalent. Associate's degree preferred.
Familiarity with medical billing codes (CPT) and claim submission procedures.
High level of accuracy in data entry and claim review.
Ability to interpret provider contract policies and billing guidelines.
Effective verbal and written communication to interact with clinicians, providers, and finance staff.
Experience with electronic health records (EHR) and billing software.
Experience with Medicaid billing preferred.
Strong analytical and problem-solving skills.

Provider Claims Processor

<h3>Job Description</h3>
Job DescriptionTTF is looking for a few A/R Specialists for full-time, contract-to-hire (or possible direct-hire) positions in Central Phoenix. The starting salary will depend on experience and our client offers excellent benefits. Job duties primarily include billing and following up with all medical insurance payors for claims. Experience working on NextGen is a plus, and working within Excel is required. Please send your resume to Chelle Bodnar at <a href="mailto:CBodnar@TTFrecruit.com" target="_blank">CBodnar@TTFrecruit.com</a> for consideration. Qualified candidates should have previous experience in medical claim billing, insurance follow-up, and have knowledge of AHCCCS guidelines. In addition, qualified candidates must have a stable work history and have the ability to pass a drug screen and background check. TTF is a search and staffing company that partners with hospitals, physician groups, TPA's, medical management companies, pharmaceutical and pharmacy benefit plan organizations, surgery centers, DME/home health, consulting companies, and all other healthcare fields. TTF places candidates in the revenue cycle, health information management, and healthcare administrative fields with the following specialties and titles: Hospital Collector, Commercial, Government, Managed Care, Billing Representative, Medical Biller, AHCCCS, Medicare, Medicaid, Medical Claims, Medical Data Entry, Follow-Up Rep, Medical Collections Representative, Medical Collector, Medical Reimbursement Specialist, Patient Account Rep, Patient Financial Representative, Reimbursement Representative, Reimbursement Specialist, Claims Processing, Credentialing Specialists, Medical Front Office, Medical Assistants, Insurance Verification, Coder, Coding, HIMS Tech, and Claims Processor. TTF never charges a fee to candidates and all conversations are kept confidential. We would like to be your career consultant and look forward to working with you #IND1

A/R Specialist- Medical Billing and Collections

<h3>Job Description</h3>
Job Description
**This position is located in Cypress, CA
Southern California United Food &amp; Commercial Workers Unions &amp; Food Employers Joint Benefit Funds Administration, LLC (The Funds) were created more than 40 years ago as a result of collective bargaining between the Southern California Retail Food Employers and the Southern California UFCW Union Locals. The Funds serve in excess of 100,000 participants! There are two Funds, the Pension Fund and the Benefit Fund--through which member retirement and health and welfare benefits are provided.
The Funds Office is currently searching for a supportive Medical Claims: Senior Claims Processor, to join our growing Healthcare Claims Team. In this role, you will be responsible for the operational efficiency and accuracy of medical claims processed by providing support to the staff and supervisor. This position is subject to Collective Bargaining. 
General Responsibilities:
<ol>
<li>Assist the Supervisor in the coordination of the Department’s daily work assignments</li>
<li>First point of contact for departmental issues.</li>
<li>Review results of adjuster audits and discuss results and opportunities with Supervisor and staff.</li>
<li>Assist in identifying, maintaining and reporting team performance as it relates to quality, production and service standards.</li>
<li>
Maintain current department knowledge of plan documents, summaries of plan provisions and other plan materials.
</li>
<li>Provide input and feedback on staff performance.</li>
<li>Identify and recommend process improvements for internal workflow, system processes and updates to benefit plans.</li>
<li>Professionally and effectively communicate with plan participants, Local Union representatives and employer representatives, in person, on the telephone, email, or US mail.</li>
<li>Handle escalated situations with courtesy and professionalism.</li>
<li>Provide excellent customer service to co-workers and other departments.</li>
<li>Demonstrate appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and the ability to facilitate problem resolution.</li>
<li>Perform other job related duties/special projects as assigned.</li>
<li>Abide by organizational and HIPAA guidelines, privacy practices, and confidentiality.</li>
<li>Comply with the policies of the Trust Fund, as set forth in the Employee Handbook.</li>
<li>Adhere to the company’s attendance policy.</li>
</ol>
Qualifications:
<ul>
<li>High School diploma or GED required</li>
<li>Associates degree or a combination of education and experience preferred</li>
<li>4-6 years prior experience in medical customer service and claims</li>
<li>PPO claims processing experience, including prior experience in WGS processing system preferred</li>
<li>Knowledge of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), Medical Terminology</li>
<li>Knowledge with International Classification of Diseases (ICD) ICD-9/ICD-10 codes and guidelines</li>
<li>Ability to manage multiple projects with various deadlines strongly desired</li>
<li>Able to utilize MS Office (Excel, Word and Outlook) proficiency required</li>
<li>Excellent customer service skills with the ability to build rapport with Plan participants, team members and other employees of the Fund</li>
</ul>
The Funds is an equal employment opportunity employer and no candidate for employment will be rejected on the basis of race, color, religion, national origin, age, marital status, or sex. Candidates with physical impairments or limitations will be considered to the extent it can be reasonably demonstrated that the duties and responsibilities can be effectively performed without endangering the individual, colleagues or surroundings.
The Funds offers exceptional benefit packages that includes a 401(K) plan, pension plan, vacation, holiday, education reimbursement and much more!
Internal Position: Medical Senior Adjuster
Company DescriptionThe Southern California United Food &amp; Commercial Workers Unions and Joint Benefit Trust Funds (UFCW) is located in Cypress, California. We serve more than 100,000 collective bargaining employees that serve in the grocery stores throughout Southern California. UFCW provides medical, dental, vision and pension benefits for the grocery workers. We take pride in supporting the valuable grocery store employees as they serve customers throughout the region. 
<h3>Company Description</h3>
The Southern California United Food &amp; Commercial Workers Unions and Joint Benefit Trust Funds (UFCW) is located in Cypress, California. We serve more than 100,000 collective bargaining employees that serve in the grocery stores throughout Southern California. UFCW provides medical, dental, vision and pension benefits for the grocery workers. We take pride in supporting the valuable grocery store employees as they serve customers throughout the region.

Medical Claims: Senior Claims Processor

$1,500 Sign-on Bonus for External Candidates.
WellMed, part of the Optum family of businesses, is seeking a Case Manager, LVN or LPN - WellMed at University to join our team in Dallas, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.
At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together
The Nurse Case Manager I (NCM) is responsible for patient case management for longitudinal engagement, coordination for discharge planning, transition of care needs and outpatient patient management through the care continuum. The Nurse Care Manager will determine medical appropriateness of outpatient services following evaluation of medical guidelines and benefit determination. The Nurse Case Manager will coordinate, or provide appropriate levels of care under the direct supervision of an RN or MD. Function is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. Function may also be responsible for providing health education, coaching and treatment decision support for patients. This role acts as a support to team members, coaching, guiding and providing feedback as necessary. The Nurse Case Manager will act as an advocate for patients and their families guide them through the health care system for transition planning and longitudinal care. The Nurse Case Manager will work in partnership with an assigned Care Advocate and Social Worker.
Primary Responsibilities:
* Engage patient, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status 
* Provide member education to assist with self-management goals; disease management or acute condition and provide indicated contingency plan 
* Identify patient needs, close health care gaps, develop action plan and prioritize goals 
* With oversight of RN and/or MD, utilizing evidence-based practice, develop interventions while considering member barriers independently 
* Provide patients with "welcome home" calls to ensure that discharged patients' receive the necessary services and resources according to transition plan 
* In partnership with care team triad, make referrals to community sources and programs identified for patients 
* Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy 
* Manages assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers 
* Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for patients 
* Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in departmental huddles 
* Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities 
* Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research 
* Manage assigned caseload in an efficient and effective manner utilizing time management skills 
* Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on 
a monthly basis 
* Maintain current licensure to work in state of employment and maintain hospital credentialing as indicated 
* Performs all other related duties as assigned
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
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:
* Licensed Practical/Vocational Nurse 
* Current, unrestricted LPN/LVN license required, specific to the state of employment 
* 2+ years of managed care and/or case management experience 
* 2+ years of clinical experience 
* Knowledge of managed care, medical terminology, referral process, claims and ICD-10 codes. 
* Proven excellent verbal and written skills
Preferred Qualifications:
* Case Management certification 
* Knowledge of utilization management and/or insurance review processes as well as current standards of care, a solid knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff 
* Proficient computer skills in Microsoft applications and Microsoft Excel 
* Proven skills in planning, organizing, conflict resolution, negotiation and interpersonal skills to work with autonomy in meeting case management goals and initiatives 
* Demonstrated ability to work independently in accomplishing assignments, program goals and objectives
Physical &amp; Mental Requirement:
* Ability to properly drive and operate a company vehicle
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law
OptumCare is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. 
By applying, you consent to your information being transmitted by Get It to the Employer, as data controller, through the Employer's data processor SonicJobs. 
See United Healthcare Privacy Policy at <a href="https://www.unitedhealthgroup.com/privacy.html" target="_blank">https://www.unitedhealthgroup.com/privacy.html</a> and SonicJobs Privacy Policy at <a href="https://www.sonicjobs.com/us/privacy-policy" target="_blank">https://www.sonicjobs.com/us/privacy-policy</a> and Terms of Use at <a href="https://www.sonicjobs.com/us/terms-conditions" target="_blank">https://www.sonicjobs.com/us/terms-conditions</a>

Case Manager, LVN or LPN - WellMed at University

WellMed, part of the Optum family of businesses, is seeking a Healthcare Clinic Coordinator to join our team in WellMed at Live Oak, Dallas, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.
At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together
The LVN Health Coach is responsible for successfully supporting Disease Management/Chronic Care Program requirements for medical group/health plan members. The Health Coach acts as an educator, resource, and advocate for members and their families to ensure a maximum level of independence. The LVN Health Coach will interact and collaborate with multidisciplinary care teams, which include physicians, nurses, pharmacists, laboratory technologists, social workers, and other educators. The LVN Health Coach will assist in providing patient empowerment through the use of motivational interviewing skills, problem solving, and self-management goal setting.
Primary Responsibilities:
* Works with the PCP and clinic staff to identify patients with high risk diagnoses such as CHF, IHD, COPD/asthma and diabetes and ensures clinical guidelines are being followed 
* Contacts and performs initial interviews with patients who are in need of health coaching programs 
* Conducts Chronic Care Model visits and reviews the patient's informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease 
* Provide necessary coaching to reduce or eliminate behaviors that are considered high-risk 
* Identify the required goals that each patient must fulfill and advice feasible options for achieving goal 
* Ensure that patients are made aware of health issues, concerns and the way in which one could combat them 
* Must raise awareness about the different available exercises, weight loss programs and other dietary requirements necessary for a healthy lifestyle 
* Utilizes appropriate motivational interviewing techniques necessary for coaching and assisting the patient to complete a self-management goal/action plan 
* Must be able to provide a chart of habits and lifestyle changes that are imperative for the improvement of the concerned patient's health 
* Enters timely and accurate data into the electronic medical record to communicate patient needs and to ensure complete documentation of patient visits and phone calls. Tracks self-management goal outcomes and documents in electronic medical record 
* Maintains current knowledge regarding CHF, IHD, COPD/asthma and diabetes as well as related treatments and complex medications 
* Assists, initiates referrals, and coordinates transitions of car regarding hospitalization follow-up, palliative care, hospice, etc. 
* Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians 
* Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms 
* Conducts clinic one-on-one visits with Disease Management Chronic Care Program participants, utilizing the Chronic Care Model, to assess patient needs for DME, home health, value-added services and any other necessary resources. Communicates these needs to the appropriate person (i.e. Social Worker, clinic staff, etc.) or addresses them per process 
* Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/asthma and diabetes 
* Performs all other related duties as assigned. i.e. IV Insertion with hydration fluid administration, wound care, dressing changes, suture removal, insertion and removal of urinary catheters, and etc.
This is a clinic base position located in Richardson, TX.
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
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:
* High school diploma or GED 
* Licensed Vocational Nurse with a current license to practice in the state of employment 
* 2+ years experience in a physician's office, clinical or hospital setting 
* Cardiac, medical-surgical and/or critical care experience 
* Experience related to patient education and/or motivational interviewing skills and self-management goal setting 
* Proficient knowledge of chronic diseases, especially COPD/asthma, diabetes, CHF and IHD 
* Proficient computer skills, including Microsoft Word, Excel, Access and Outlook 
* Driver's License and access to a reliable transportation 
* This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor's diagnosis of disease
Preferred Qualifications:
* 5+ years of experience in a physician's office, clinical or hospital setting 
* Bilingual Spanish skillset 
* Knowledge of managed care, referral processes, claims and ICD-9 and CPT coding 
* Proven excellent verbal and written skills 
* Proven ability to interact productively with individuals and with multidisciplinary teams 
* Proven excellent organizational and prioritization skills
The hourly range for this role is $19.86 to $38.85 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. 
By applying, you consent to your information being transmitted by Get It to the Employer, as data controller, through the Employer's data processor SonicJobs. 
See United Healthcare Privacy Policy at <a href="https://www.unitedhealthgroup.com/privacy.html" target="_blank">https://www.unitedhealthgroup.com/privacy.html</a> and SonicJobs Privacy Policy at <a href="https://www.sonicjobs.com/us/privacy-policy" target="_blank">https://www.sonicjobs.com/us/privacy-policy</a> and Terms of Use at <a href="https://www.sonicjobs.com/us/terms-conditions" target="_blank">https://www.sonicjobs.com/us/terms-conditions</a>

Healthcare Clinic Coordinator WellMed at Live Oak, Dallas, TX

$1,500 Sign On Bonus For External Candidates 
8 days of PTO &amp; Closed on Major Holidays, 401K Match
WellMed, part of the Optum family of businesses, is seeking a LVN Case Manager to join our team in Dallas, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live. 
As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone. 
At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.
The Nurse Case Manager I (NCM) is responsible for patient case management for longitudinal engagement, coordination for discharge planning, transition of care needs and outpatient patient management through the care continuum. The Nurse Care Manager will determine medical appropriateness of outpatient services following evaluation of medical guidelines and benefit determination. The Nurse Case Manager will coordinate, or provide appropriate levels of care under the direct supervision of an RN or MD. Function is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. Function may also be responsible for providing health education, coaching and treatment decision support for patients. This role acts as a support to team members, coaching, guiding and providing feedback as necessary. The Nurse Case Manager will act as an advocate for patients and their families guide them through the health care system for transition planning and longitudinal care. The Nurse Case Manager will work in partnership with an assigned Care Advocate and Social Worker.
Position Highlights &amp; Primary Responsibilities:
* Engage patient, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status 
* Provide member education to assist with self-management goals; disease management or acute condition and provide indicated contingency plan 
* Identify patient needs, close health care gaps, develop action plan and prioritize goals 
* With oversight of RN and/or MD, utilizing evidence-based practice, develop interventions while considering member barriers independently 
* Provide patients with "welcome home" calls to ensure that discharged patients' receive the necessary services and resources according to transition plan 
* In partnership with care team triad, make referrals to community sources and programs identified for patients 
* Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy 
* Manages assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers 
* Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for patients 
* Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in departmental huddles 
* Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities 
* Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research 
* Manage assigned caseload in an efficient and effective manner utilizing time management skills 
* Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on a monthly basis 
* Maintain current licensure to work in state of employment and maintain hospital credentialing as indicated 
* Performs all other related duties as assigned
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
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:
* Licensed Practical/Vocational Nurse 
* Current, unrestricted LPN/LVN license required, specific to the state of employment 
* 2+ years of managed care and/or case management experience 
* 2+ years of clinical experience 
* Proven excellent verbal and written skills 
* Proven knowledge of managed care, medical terminology, referral process, claims and ICD-10 codes
Preferred Qualifications:
* Case Management certification 
* Demonstrated skills in planning, organizing, conflict resolution, negotiation and interpersonal skills to work with autonomy in meeting case management goals and initiatives 
* Proven knowledge of utilization management and/or insurance review processes as well as current standards of care, a solid knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff 
* Ability to work independently in accomplishing assignments, program goals and objectives 
* Proficient computer skills in Microsoft applications and Microsoft Excel
The hourly range for this role is $19.86 to $38.85 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. 
By applying, you consent to your information being transmitted by Get It to the Employer, as data controller, through the Employer's data processor SonicJobs. 
See United Healthcare Privacy Policy at <a href="https://www.unitedhealthgroup.com/privacy.html" target="_blank">https://www.unitedhealthgroup.com/privacy.html</a> and SonicJobs Privacy Policy at <a href="https://www.sonicjobs.com/us/privacy-policy" target="_blank">https://www.sonicjobs.com/us/privacy-policy</a> and Terms of Use at <a href="https://www.sonicjobs.com/us/terms-conditions" target="_blank">https://www.sonicjobs.com/us/terms-conditions</a>

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