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<h3>Job Description</h3>
Job DescriptionDescription:
SEIU Healthcare IL Benefit Funds is a dynamic benefits administration organization committed to providing the highest quality health and retirement benefits in the most financially responsible manner, while always acting in the best interest of the union members. The Fund serves over 20,000 union workers in the Nursing Home, Home Care, Child Care, and Personal Assistant industries with the delivery of health and pension benefits. Our employees epitomize the Fund’s core values of quality service, interdependence, effectiveness, and accountability, and forge an alliance with one another to carry out our shared mission and common agreements for those we serve. 
 
Position Summary:
The Claims Examiner, Level 1, is responsible for analyzing, processing, and auditing PPO, HMO and other medical claims for plan participants who are union members of SEIU Healthcare Illinois and Indiana (HCII). Claims Examiners are able to handle and accurately adjudicate assigned medical claims following established guidelines and industry best practices with a minimal amount of supervision.
 
This position must maintain excellent working relationships with peers in the Claims Department and interdepartmentally, vendors, medical providers, plan participants and all key stakeholders related to the Fund Office.
Claims Examiner, Level 1 will be responsible for the following:
 
Key Duties and Responsibilities:
<ul>
<li>Process medical and facility claims in an accurately and timely manner; ensure all necessary information is present including accident details/subrogation form, other insurance information, referral and/or pre-certification, repricing, auditing, and all other information needed to properly process the claim</li>
<li>Review and adjudicate claims for compliance with contract terms, benefit coverage, and regulatory requirements.</li>
<li>Review provider reconsiderations and reprocess the claim or generate letter(s) in response to the request.</li>
<li>Respond to inquiries from coworkers or other departments via email or a ticketing system within three (3) business days.</li>
<li>Apply appropriate pricing and coding standards (e.g., CPT, ICD-10, System Benefit codes) and reimbursement methodologies to ensure accurate claim payment.</li>
<li>Process check-run cycles and check run audits when assigned.</li>
<li>Perform audits of auto-adjudicated claims when assigned.</li>
<li>Attend meetings with vendors, providers, partnering organizations or any other meeting as assigned.</li>
<li>Identify and report system issues, test and troubleshoot system configuration, completing reports, and run other system tasks or reports as assigned.</li>
<li>Monitor pended claims to ensure unnecessary delays are avoided.</li>
<li>Monitor claims inventory to assure consistent processing time across the plans.</li>
<li>Correspond to providers, members and external vendors via mail, email or phone.</li>
<li>Attend and participate in various meetings, including monthly All Staff meetings, department meetings, training sessions, task force or committee meetings, and other meetings as deemed appropriate to share, discuss, and solution for question or error trends, as well as identify potential process improvements.</li>
<li>Create one-on-one (1:1) agendas with the Claims Supervisor using the Purpose, Outcome and Process (POP) Model and keeping thorough notes for each meeting.</li>
<li>Back-up all duties of the Claims Clerk as needed.</li>
</ul>
Privacy and Security Responsibilities:
This position requires employees to handle Personal Identifiable Information (PII) and Protected Health Information (PHI) for our members. You will be responsible and accountable for maintaining the confidentiality, integrity, and availability of all PII and PHI. Report any suspected HIPAA violation or breach to our HIPAA Privacy and Security Officer.
 
 
Requirements:
Job Requirements
 
Education Requirements:
<ul>
<li>High School diploma or GED equivalent</li>
<li>Associate degree or higher in Health Care, Business Administration, or similar field is preferred</li>
</ul>
Job Requirements:
<ul>
<li>Minimum of five (5) years of experience in medical claims examination, preferably in a managed care operation or insurance setting.</li>
<li>Meet or exceed 98% financial and 95% procedural for quality and production standards.</li>
<li>Knowledge and understanding of the health care industry, including medical claim processing, subrogation, ICD-10 Diagnosis Codes, CPT Procedures Coding, HCPC Codes, HCFA 1500, and UB-02 claim forms.</li>
<li>Strong analytical skills with the ability to interpret complex medical documentation and make sound claim decisions.</li>
<li>Excellent attention to detail and accuracy in data entry and claim adjudication.</li>
<li>Knowledge of healthcare regulations, compliance requirements, and industry standards related to claims processing.</li>
<li>Proficient use of desktop computers, laptop computers, printers, copiers, scanners, fax and other office equipment.</li>
<li>Ability to type 35 words per minute accurately.</li>
<li>Proficient skills, intermediate to expert level, in Microsoft Office Suite (Word, Excel, Access, Power Point, Visio, and Outlook) </li>
<li>Excellent written and verbal communication skills</li>
<li>Excellent interpersonal and customer services skills required</li>
<li>Ability to develop and maintain positive working relationships with both internal and external stakeholders</li>
<li>Strong analytical mindset</li>
<li>Ability to organize and prioritize task</li>
<li>Ability to demonstrate teamwork and work independently</li>
<li>Ability to meet deadlines</li>
<li>Exercise clear and concise judgment</li>
<li>Ability and willingness to assist in special projects and handle multiple tasks</li>
</ul>
Preferred Skills:
<ul>
<li>Taft-Hartley experience</li>
<li>Knowledge of the Fund’s benefit administration system (Basys/Bridgeway)</li>
<li>Experience with project management software, such as Smartsheet</li>
<li>Experience working in a hybrid environment, in-person and remote </li>
<li>Experience with virtual conference software (Teams and Zoom)</li>
</ul>
Career Development &amp; Continuing Education Opportunities: Yes
 
Benefits:
SEIU Healthcare IL Benefit Funds offers a comprehensive health benefits (medical, dental and vision coverage) for employees and eligible dependents, including no employee premium option for employee only; competitive compensation; generous holidays and PTO policies; and a pension retirement plan.
 
Diversity creates a healthier atmosphere: SEIU Healthcare IL Benefit Funds 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.
 
The SEIU Healthcare IL Benefit Funds vision is to create a more just and equitable society that fosters a lifetime of quality healthcare and financial security for all. We hope that our social justice values and the responsibility we take to operate a socially conscious organization aligns with your professional desire to contribute and serve with purpose.

Claims Examiner Level 1

<h3>Job Description</h3>
Job Description
Who are we? A strategic and trusted insurance partner, Berkshire Hathaway Specialty Insurance (BHSI), provides a broad range of commercial property, casualty and specialty insurance coverages and outstanding service to customers and brokers around the world. Part of Berkshire Hathaway’s insurance operations, we bring our solutions to market with our stellar brand name, top-rated balance sheet, and the expertise of our global team of professionals, who exude excellent capabilities and strong character.
We are a values-based organization where respect, integrity, excellence, collaboration, and passion define who we are and how we do business. We value diversity of backgrounds, experience, and perspectives and strive to foster an inclusive environment that enables all our team members to bring their best selves to work. We are one team committed to building a culture where every teammate has the opportunity to contribute and be recognized. Want to be part of the team building the finest property, casualty, and specialty lines insurance company in the world?
Learn more about our unique culture and history.
 
Job Opportunity: 
Berkshire Hathaway Specialty Insurance (BHSI) has an exciting opportunity for an experienced Multi-Line Claims Examiner to join our dynamic Claims team. The Examiner will be responsible for handling of specialty lines claims and management oversight of TPA claims as well as some handling of individual claim files, collaborating with underwriters throughout the claims process and marketing BHSI Claim Service to customers. We are seeking candidates with a high level of technical skill, as well as excellent communication and interpersonal skills. The position will be based in either our New York, Boston or Atlanta office. 
 
Duties &amp; Responsibilities:
<ul>
<li>Responsible for oversight, managing and adjusting of primary and TPA claims to include; commercial auto, general casualty, errors &amp; omission, accident &amp; health, homeowner and commercial property claims. Ensure high level of customer service and technical claim file quality.</li>
<li>Duties include proactive handling of claims from first notice of loss through ultimate resolution, working and advising internal partners on claims, developing a plan of action for ultimate resolution, obtaining budgets and meeting with clients and brokers. Audit and oversite of TPA claims.</li>
<li>Provides outstanding customer service and works well with the insured, broker and TPA in the handling and adjudication of claims.</li>
<li>Analyze and draft coverage letters as appropriate and communicates coverage positions effectively.</li>
<li>Conducts, coordinates, and proactively directs investigation, defense and settlement of claims.</li>
<li>Directs and closely monitors assignments to experts and defense counsel.</li>
<li>Evaluates information on coverage, liability, and damages to determine the extent of exposure to the insured and the company.</li>
<li>Drafts reports, sets reserves within authority or make claim recommendations concerning reserve changes.</li>
<li>Travels to audits, conferences, mediations, and trials as necessary</li>
</ul>

 Qualifications, Skills, and Experience:
<ul>
<li>Should have a high degree of specialized and technical competence in the handling multi line claims.</li>
<li>Minimum of 3 -5 years multi line claim handling experience.</li>
<li>College degree preferred.</li>
<li>Ability to work independently and assimilate learning materials on many different subjects from various sources.</li>
<li>Excellent interpersonal communications and negotiation skills.</li>
<li>Ability to work in a team environment.</li>
<li>Should have technical competence in all aspects of multi-line claims with particular emphasis on customer service.</li>
<li>Experience in handling and adjusting claims in all 50 states and possess required licenses.</li>
</ul>
 
BHSI Offers:
<ul>
<li>A competitive package and exciting growth opportunities for career-oriented teammates.</li>
<li>A dynamic, action oriented, and thoughtful environment centered on always doing the right thing for our customers, teammates, and our other stakeholders.</li>
<li>A purposely non-bureaucratic organization that embraces simplicity over complexity and emphasizes individual excellence in a team framework.</li>
<li>Benefits that support your life and well-being, which include:</li>
</ul>
<ul>
<ul>
<li>Comprehensive Health, Dental and Vision benefits</li>
<li>Disability Insurance (both short-term and long-term)</li>
<li>Life Insurance (for you and your family)</li>
<li>Accidental Death &amp; Dismemberment Insurance (for you and your family)</li>
<li>Flexible Spending Accounts</li>
<li>Health Reimbursement Account</li>
<li>Employee Assistance Program</li>
<li>Retirement Savings 401(k) Plan with Company Match</li>
<li>Generous holiday and Paid Time Off</li>
<li>Tuition Reimbursement</li>
<li>Paid Parental Leave</li>
</ul>
</ul>

The base salary range for this position is $60,000 to $80,000, along with annual bonus eligibility. Total compensation for a candidate is determined by their relevant skills, location, and experience. We value our teammates – both their capabilities and character – as demonstrated by our amazing culture.
NOTE: Compensation will be commensurate with experience. This job description is not intended to be all-inclusive. Team Member may perform other related duties as negotiated to meet the ongoing needs of the organization.

Claims Examiner, Programs

<h3>Job Description</h3>
Job Description
Summary:
A Hospital Claims Auditor is responsible for the overall quality of claims processes as well as compliance, in accordance with outside regulations and the contractual obligations of the Health Plans and/or Hospital Clients. Research, reviews and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff. The Claims auditor also performs special projects and helps department manager and director as needed. They review and audit the Examiners’ adjudicated claims for accuracy and providing feedback.
Duties and Responsibilities:
· Audit daily processed claims through random selection as outlined by organizational Policies and Procedures. Utilize appropriate system-generated reports applicable to specialty claims.
· Conduct Claims Examiner training as required. Document training materials and attendees.
· Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions to Senior Management.
· Work with other organizational departments
· Assist in the development of Claims Department Policies and Procedures.
· Provide backup for other auditors/trainers within the Department.
· Perform other tasks as assigned by Senior Management.
· Promote a spirit of cooperation and understanding among all personnel.
· Attend organizational meetings as required
· Adhere to organizational Policies and Procedures.
· Adhere to MedPOINT Management’s core value: Accountability, Community, Celebration, Integrity, Innovation &amp; Collaboration
Minimum Job Requirements:
· High School Diploma required.
· Three years of experience in a managed care claims adjudication setting e.g., HMO/MSO, required.
· Expertise in coding structure, ICD-10, CPT-4 and Revenue Codes, required.
· Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.
Knowledge, Skills and Abilities Required:
· Strong organizational, analytical and oral/ written communication (English) skills required.
· Proficiency in PC application skills, e.g., word processing, spreadsheets, preferred
· Experience in training development and presentation preferred
· Must be able to follow directions and also perform independently according to departmental standards.

Hospital Claims Auditor

<h3>Job Description</h3>
Job DescriptionDescriptionAbout Reserv
Reserv is an insurtech creating and incubating cutting-edge AI and automation technology to bring efficiency and simplicity to claims. Founded by insurtech veterans with deep experience in SaaS and digital claims, Reserv is venture-backed by Bain Capital and Altai Ventures and began operations in May 2022. We are focused on automating highly manual tasks to tackle long-standing problems in claims and set a new standard for TPAs, insurance technology providers, and adjusters alike.
We have ambitious (but attainable!) goals and need adjusters who can work in an evolving environment. If building a leading TPA and the prospect of tackling the long-standing challenges of the claims role sounds exciting, we can't wait to meet you. 
About the role
We are seeking a skilled BI-LIT Claims Examiner to manage litigated files and attend trials, conferences, mediations, and arbitrations. The successful candidate will:
<ul>
<li>Investigate and gather all necessary information and documentation related to claims</li>
<li>Evaluate liability and damages</li>
<li>Negotiate and settle claims</li>
<li>Manage litigation cases related to auto claims disputes</li>
</ul>
The BI-LIT Claims Examiner will also be responsible for maintaining electronic files, analyzing defense counsel's performance, and regularly reporting to the Claims Manager. In addition, you will collaborate closely with our product and engineering teams to give feedback and identify technology and process improvements.
Who you are
<ul>
<li>Highly motivated and growth-oriented. You're excited by the prospect of building a tech-driven claims org.</li>
<li>Passionate adjuster who cares about the customer and their experience.</li>
<li>Empathetic. You exercise empathy and patience towards everyone you interact with. </li>
<li>Sense of urgency - at all times. That does not mean working at all hours.</li>
<li>Creative. You can find the right exit ramp (pun intended) for the resolution of the claim that is in the insured's best interest. </li>
<li>Conflict-enjoyer. Conflict does not have to be adversarial, but it HAS to be conversational. </li>
<li>Curious. You have to want to know the whole story so you can make the right decisions early and action them to a prompt resolution. </li>
<li>Anti-status quo. You don't just wish things were done differently, you action on it. </li>
<li>Communicative. (we'd love to know what this means to you)</li>
<li>And did we mention, a sense of humor. Claims are hard enough as it is. </li>
</ul>
What we need
We need you to do all the things typical to the role:
<ul>
<li>Managing legal aspects of litigated cases, including evaluation of legal process and expenses</li>
<li>Analyzing and reviewing auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers</li>
<li>Managing litigation cases related to auto claims disputes, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders</li>
<li>Collaborating with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry</li>
<li>Reviewing legal documents and ensuring compliance with initial suit-handling plan of action</li>
<li>Serving as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed</li>
<li>Analyzing policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing primarily litigated claim files from inception to closure</li>
<li>Directing and controlling the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters</li>
<li>Maintaining adjuster licenses and continuing education requirements</li>
</ul>
Requirements
<ul>
<li>Bachelor's degree (lack of one should not stop you from applying if you possess all the other qualifications)</li>
<li>10+ years of claim handling experience, with 5+ of those years handling a pending of &gt;60% in litigation</li>
<li>Transportation litigation (rideshare, auto, trucking, etc) is preferred but those with personal lines experience should still apply if they meet all other requirements.</li>
<li>You are not intimidated by an attorney, even if you are not one! You are the driver of the litigation strategy for any particular claim. You manage the discovery in the order and timing of events and hold attorney accountable</li>
<li>Understand transportation coverages. Understand contractual risk transfer and additional insured forms</li>
<li>You have strong medical knowledge </li>
<li>You have a sense of urgency and understanding of how to manage time-sensitive demands</li>
<li>Ability and willingness to communicate both on the phone and in written form in a prompt, courteous, and professional manner</li>
<li>Strong analytical and negotiation skills. You will conduct your own negotiations directly with opposing counsel</li>
<li>Knowledge of multiple state statutes, including good faith claim handling practices, regulations, and guidelines</li>
<li>Ability to professionally collaborate with all stakeholders in a claim</li>
<li>Have active adjuster license(s) and be willing to obtain all licenses within 45 days, including completing state required testing</li>
<li>Attention to detail, time management, and the ability to work independently in a fast-paced, remote environment</li>
<li>Curious and motivated by problem solving and questioning the status quo</li>
<li>Desire to engage in learning opportunities and continuous professional development</li>
<li>Willingness to travel for client and claims needs</li>
</ul>
Benefits
<ul>
<li>Generous health-insurance package with nationwide coverage, vision, &amp; dental</li>
<li>401(k) retirement plan with employer matching</li>
<li>Competitive PTO policy – we want our employees fresh, healthy, happy, and energized!</li>
<li>Generous family leave policy</li>
<li>Work from anywhere to facilitate your work life balance</li>
<li>Apple laptop, large second monitor, and other quality-of-life equipment you may want. Technology is something that should make your life easier, not harder!</li>
</ul>
Additionally, we will
<ul>
<li>Provide a manageable pending for you to deliver the service in a way you've always wanted and a dedicated account</li>
<li>Listen to your feedback to enhance and improve upon the long-standing challenges of an adjuster </li>
<li>Work toward reducing and eliminating all the administrative work from an adjuster role</li>
<li>Foster a culture of empathy, transparency, and empowerment in a remote-first environment</li>
</ul>
At Reserv, we value diversity in backgrounds, perspectives, and life experiences and believe that diversity in viewpoints and critical thinking drives innovation, first-principles thinking, and success. We welcome applicants from all backgrounds and encourage those from all walks of life to apply. If you believe you are a good fit for this role, we would love to hear from you!

Litigation Claims Examiner

<h3>Job Description</h3>
Job DescriptionClaims Service AssistantLocation: Concord, CA Pay Range: $20-24/hrTemp-to-HireWe are seeking a Claims Service Assistant to join a leading insurance firm where your attention to detail and organizational skills will make a real impact! This opportunity offers a blend of claims processing and mailroom responsibilities, perfect for someone who thrives on accuracy, enjoys multi-tasking, and values being a trusted resource for confidential information. If you’re ready to take on a role where your integrity and commitment to quality are valued, call Brett @ 888-303-5627 to discuss this opportunity!What You’ll Do
<ul>
<li>Accurately input claims, payments, and policy information into management systems</li>
<li>Prepare, organize, and distribute sensitive documents and mail</li>
<li>Maintain and retrieve files from storage, ensuring compliance with confidentiality standards</li>
<li>Support subpoena compliance and process ISO (index search) requests</li>
<li>Scan, quality check, and index claim files as assigned</li>
<li>Provide backup receptionist coverage and assist with daily check runs</li>
</ul>
What You’ll Bring
<ul>
<li>High school diploma or GED required; AA/AS or BA/BS a plus</li>
<li>At least 1 year of data entry experience</li>
<li>Strong organizational, verbal, and written communication skills</li>
<li>Ability to multi-task, prioritize, and meet deadlines with accuracy</li>
<li>Proficiency in Microsoft Office and ability to learn new systems</li>
<li>Reliable, trustworthy, and team-oriented mindset</li>
</ul>
Why You’ll Love This Job
<ul>
<li>Be part of a team that values integrity, confidentiality, and service</li>
<li>Opportunity to build your skills in a dynamic office setting</li>
<li>Make a difference by ensuring the accuracy and security of critical information</li>
</ul>
Copy this link to share this opportunity! Dynamic provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Claims Service Assistant

<h3>Job Description</h3>
Job DescriptionJob Posting: Medical Claims ProcessorJob Description
Foundation for Medical Care of Kern County and HealthEdge Administrators is currently recruiting a Medical Claims Processor in Bakersfield, CA. We are looking for the right candidate to join our team! The ideal candidate has extensive professional medical claims processing, billing and/or coding experience, payment posting, insurance and benefits plan knowledge. Familiarity with Medicare guidelines is a plus. Attention to detail, critical thinking/decision making and adaptability are critical skills for this role. Previous medical claims processing experience preferred.
As a key member of our claims department, the Medical Claims Processor will be responsible for maintaining compliance with regulatory standards, and ensuring timely processing of claims. The ideal candidate will bring a strong attention to detail, excellent organizational skills, and a robust knowledge of medical terminology, medical insurance and healthcare knowledge. This is a critical role within our organization and requires a dedicated professional committed to upholding the standards of the Foundation for Medical Care of Kern County.
Our work environment includes:
<ul>
<li>Modern office setting</li>
<li>Work-from-home days</li>
<li>Growth opportunities</li>
<li>On-the-job training</li>
<li>Relaxed atmosphere</li>
<li>Regular social events</li>
</ul>
Duties and Responsibilities
<ul>
<li>Processes medical claims with attention to detail and accuracy.</li>
<li>Conducts detailed research to analyze claims information accurately.</li>
<li>Evaluates benefit plans and fee schedules to ensure thorough and proper claims processing.</li>
<li>Follows established guidelines set forth by Company, clients, and regulatory bodies.</li>
<li>Meets or exceeds departmental production goals as determined by the Claims Manager.</li>
<li>Maintains and updates claim files, including notes and electronic records.</li>
<li>Communicates effectively with healthcare providers, patients, and insurance companies to solve claims-related issues.</li>
<li>Maintains confidentiality and security of patient information according to privacy regulations and company policy.</li>
<li>Participates in training sessions to stay updated on industry trends or changes in regulations.</li>
<li>Assists in the implementation of new processes to enhance workflow efficiency.</li>
</ul>
Requirements
<ul>
<li>Must possess knowledge of medical terminology and benefits, CPT, HCPCS, Revenue and ICD10 codes.</li>
<li>Must possess knowledge of professional medical claims, including modifiers and medical procedures.</li>
<li>Detail-oriented, self-starter with a strong desire to learn.</li>
<li>Thoroughly researches and analyzes information, thinks critically.</li>
<li>Able to adapt quickly to changing processes.</li>
<li>Proficient in data-based systems and related technical software programs.</li>
<li>Must possess the ability to perform mathematic equations.</li>
<li>Must have high level of attendance in accordance with FMC Attendance Policy.</li>
<li>High school diploma or equivalent required.</li>
<li>Two years’ professional medical office experience, medical billing, payment posting, claims or appeals processing required.</li>
<li>Certified Coder preferred.</li>
<li>Familiarity with Medicare guidelines preferred.</li>
</ul>

Medical Claims Processor

<h3>Job Description</h3>
Job Description
Description of services: 
Audit a portion, as mutually agreed between the parties, of the combined financially stratified/attribute claim sample of medical and dental claims processed by medical care administrators. During the identified audit period (i.e., audits performed in 2024 will review claims processed through January 1, 2023 - through December 31, 2023, etc.). The audits will be conducted virtually with each administrator.
 
Tasks, Activities and Deliverables
The claims audit elements include review and validation:
The claimant was eligible for benefits on the date(s) of service based on data in the administrator's eligibility files, 
<ul>
<li> The provider's network participation was correctly determined based on the date of service, </li>
<li> Claims requiring utilization review approval were reviewed and processed in accordance with utilization review decisions, </li>
<li> Deductibles, coinsurance and other appropriate cost-sharing features of the benefit plan were considered and correctly applied, </li>
<li> The claim data was entered into the claim system correctly, and whether a paper claim was keyed or scanned, </li>
<li> Appropriate checks were made to ensure that there was no other coverage available to the claimant or, if there was other coverage, payments were coordinated correctly, </li>
<li> The "reasonable and customary" or provider discount features of the plan were correctly applied, including unbundling for physician services, </li>
<li> Appropriate edits were made to ensure that the claim was not paid twice, </li>
<li> The procedure(s) billed and paid were, in fact, covered by the plan and do not appear to be fraudulent billings by the provider, </li>
<li> The mathematics and computations were correct, </li>
<li> Any pre-authorization limits were appropriately applied, </li>
<li> The paper claim form was completed appropriately and signed by the appropriate parties, </li>
<li> The administrator adhered to its own internal policies and procedures when processing the claim, </li>
<li> Appropriate approvals were applied to high dollar claims (pre- and post-payment), and</li>
<li>Sufficient documentation was included in the file to support the adjudication of the claim.</li>
</ul>
Education and Experience
<ul>
<li>Bachelor's degree in accounting, finance, or a related field such as health information management.</li>
<li>At least three years of experience as a claims auditor or similar role in the health care industry. </li>
</ul>
Skills
<ul>
<li>Strong analytical and problem-solving skills</li>
<li>Excellent attention to detail</li>
<li>Ability to communicate complex information effectively and clearly</li>
<li>Good understanding of insurance policies and regulations</li>
<li>Proficiency in using computer software such as Microsoft Office Suite</li>
</ul>
Personal Attributes
<ul>
<li>Ability to work independently and in a team environment.</li>
<li>High level of integrity and ethical behavior.</li>
<li>Strong organizational and time-management skills.</li>
<li>Flexible and adaptable to change.</li>
</ul>

Claims Quality Auditor

<h3>Job Description</h3>
Job Description
Education and / or Experience:
<ul>
<li>High School Diploma and 3 years adjudication experience in a managed care setting.</li>
<li>Knowledge of CPT-4, HCPCS, Hospital Revenue, and ICD-9 coding.</li>
<li>Knowledge of HMO, DHS, DMHC, and CMS claims processing guidelines.</li>
<li>Strong knowledge of Microsoft Windows environment such as Word and Excel.</li>
<li>Self-starter, willing to take on multiple tasks.</li>
<li>Must meet minimal claims adjudication production standards.</li>
<li>Strong knowledge of Coordination of Benefits (COB) applications.</li>
<li>Must be able to interpret health plan benefits.</li>
<li>Must be able to review, interpret and apply contract rates.</li>
<li>Ability to communicate effectively orally and written typing 35 words per minute.</li>
<li>Strong organizational skills with emphasis on prioritizing and attention to details</li>
</ul>
Position Summary:
To evaluate and determine the appropriate path and to assist in the expedited processing of all claims, special projects and escalated reconsiderations originating from various internal and external sources and to serve as the first level of telephonic and written response for such issues.
Essential Duties and Responsibilities include the following:
<ul>
<li>Maintain the workflow of all departmental projects.</li>
<li>Provide reports and on-going updates to Claims management.</li>
<li>Assist in the processing of claims, special projects and medical records from all sources.</li>
<li>Oversees staff activities to maintain high level of productivity.</li>
<li>Monitor claims related functions to ensure health plan and regulatory compliance.</li>
<li>Participate with training determined by unit Supervisor regarding claims adjudication issues discovered in audit or through appeals.</li>
<li>Perform audits of claims activities such as turnaround time for acknowledgement, forwarding of claims to correct payer, and processing timeframes.</li>
<li>Provide primary support to the Supervisor of the Institutional unit including special projects.</li>
<li>Recommend process improvements based on appeal tracking and trending reports.</li>
<li>Support Claims management in other company functions such as Medical Review management.</li>
<li>Handle and document resolution to escalated telephone and written claims.</li>
<li>Implement and coordinate issue resolution processes.</li>
<li>Liaison for department with outside providers and internal departments.</li>
<li>Provide supervisory coverage for Claims unit as needed.</li>
<li>All other duties as directed by management.</li>
</ul>
The pay range for this position at commencement of employment is expected to be between&nbsp;&nbsp;$28 - $30 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare &amp; Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
<ul>
<li>Employer-paid comprehensive medical, pharmacy, and dental for employees</li>
<li>Vision insurance</li>
<li>Zero co-payments for employed physician office visits</li>
<li>Flexible Spending Account (FSA)</li>
<li>Employer-Paid Life Insurance</li>
<li>Employee Assistance Program (EAP)</li>
<li>Behavioral Health Services</li>
</ul>
Savings and Retirement:
<ul>
<li>401k Retirement Savings Plan</li>
<li>Income Protection Insurance</li>
</ul>
Other Benefits:
<ul>
<li>Vacation Time</li>
<li>Company celebrations</li>
<li>Employee Assistance Program</li>
<li>Employee Referral Bonus</li>
<li>Tuition Reimbursement</li>
<li>License Renewal CEU Cost Reimbursement Program</li>
<li>Business-casual working environment</li>
<li>Sick days</li>
<li>Paid holidays</li>
<li>Mileage</li>
</ul>
Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Company DescriptionAs one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare &amp; Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success. 
<h3>Company Description</h3>
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare &amp; Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Claims Adjudication Examiner

<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.
Summary of role:
The Claims QA Auditor is primarily responsible for pre-payment, post-payment, and adjudication audits of claims across multiple employer groups and products, including complex high-dollar claims. This includes handling all aspects of the Claims Quality Review program, establishing processing standards, responding to quality issues, assisting in implementing performance improvement plans, providing data for performance guarantee service level agreements, and assisting with ensuring reports are completed and distributed timely.
Responsibilities Include:
<ul>
<li>
Perform auditing of claims, ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
</li>
<li>
Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
</li>
<li>
Responsible to communicate corrections and adjustments to Examiners as identified on pre-payment audits, including high dollar claims, and to verify corrections and adjustments are complete and accurate.
</li>
<li>
Identify and escalate trends based on the quality reviews.
</li>
<li>
Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
</li>
<li>
May investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
</li>
<li>
Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring examiners through quality improvement plans.
</li>
</ul>
Qualifications:
Required Skills and Abilities:
<ul>
<li>
Prior experience with a highly automated and integrated claims processing system, El Dorado-Javelina or Health Rules Payer (HRP) preferred.
</li>
<li>
Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
</li>
<li>
Strong analytical, organizational, and interpersonal skills, with the ability to communicate effectively with others.
</li>
<li>
Attention to detail, organized, quality and productivity driven.
</li>
</ul>
Education and Experience:
<ul>
<li>
High School diploma or GED required.
</li>
<li>
Associate or bachelor’s degree preferred.
</li>
<li>
Minimum of three (3) years of experience as a claim examiner and/or auditor with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards.
</li>
<li>
Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.
</li>
</ul>
Preferred Qualifications:
<ul>
<li>
Ability to acquire and perform progressively more complex skills and tasks in a production environment.
</li>
<li>
Ability to work under limited supervision and provide guidance and coaching to others.
</li>
<li>
Excellent coaching skills and ability to mentor others towards quality improvement.
</li>
</ul>
Work Location:
Candidates located within commuting distance of our Buffalo office will be considered for both in-person and hybrid roles. All other applicants will be considered for remote positions.
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: $55K - $60K

Claims QA Auditor

<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 utilizing resources to efficiently review, price and process medical claims with outside vendors. Handle complex file reviews related to network pricing. This is a FT WFH role. Pay Range $19.05 - $21.43 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=27758451&amp;refresh=true" target="_blank">https://j.brt.mv/jb.do?reqGK=27758451&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>High School diploma or equivalent.</li>
<li>2 – 3 years medical/dental claim processing or customer service dealing with all types of plans/claims.</li>
<li>Professional and effective written and verbal communication skills.</li>
<li>Good analytical, problem solving, decision making and organizational, and detail-oriented skills with ability to shift priorities.</li>
<li>10-key proficiency of 105 spm.</li>
<li>Type a minimum of 45 wpm.</li>
<li>Good organizational ability to work under pressure to handle variety of functions and meet timelines.</li>
<li>Ability to maintain confidentiality and project a professional business image.</li>
<li>Ability to come into work on time and on a daily basis.</li>
<li>Proficient with Facets, Word, and Excel.</li>
</ul>
 Primary Functions:
<ul>
<li>Prices and processes medical claims with outside vendors including First Choice, IPN, Healthy Directions, PHCS-PPO, and First Health.</li>
<li>Work closely with Medical Professional Relations, Customer Service, and Support on pricing requests.</li>
<li>Able to differentiate between all plan types when processing claims for multiple groups.</li>
<li>Identify inconsistencies with network setups.</li>
<li>Contacts outside vendors related to pricing and website issues.</li>
<li>Review, analyze and resolve claims through the utilization of available resources including P&amp;Ps, member handbooks, provider contracts, and EBT.</li>
<li>Complete complex file reviews associated with network pricing.</li>
<li>Handle claim adjustments related to network pricing.</li>
<li>Assist with Member and Providers Appeals related with network pricing.</li>
<li>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.</li>
<li>Internally with Medical Claims, Customer Service, Support, Medical Professional Relations. Externally with outside vendors.</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.

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