Claims Resolution Specialist II Job at Baptist Health (Florida) (Jacksonville)

Care Management Specialist II (RN or LCSW)

The Care Management Specialist II utilizes clinical skills and training to perfo...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments
Experience providing care management with complex/catastrophic conditions
Current knowledge of clinical standards of care and disease processes
Critical thinking skill
Excellent customer service skills
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions
Ability to triage immediate member health and safety risks
Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping
Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders
Ability to use a personal computer, and knowledge of medical information systems

Job Responsibility

Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs
Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives
reviewing member claims histories and identifies intervention opportunities through the professional standards of practice
contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits
conducting comprehensive clinical assessments as indicated
developing a member centric plan of care
Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence)
Collaborates with primary care physician and other treating professionals as appropriate
Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes
Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Care Management Specialist II

Established in 1997, L.A. Care Health Plan is an independent public agency creat...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing for Registered Nurses
Master's Degree in Social Work for Licensed Clinical Social Workers
Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments
Experience providing care management with complex/catastrophic conditions
Current knowledge of clinical standards of care and disease processes
Critical thinking skill
Excellent customer service skills
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions
Ability to triage immediate member health and safety risks
Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping

Job Responsibility

Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs
Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives
reviewing member claims histories and identifies intervention opportunities through the professional standards of practice
contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits
conducting comprehensive clinical assessments as indicated
developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence)
Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies
Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions
Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines
Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Appeals and Grievance Specialist II - HP Appeals Grievances

This position requires the ability to work independently researching and reviewi...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Associate Degree Preferred
Previous Appeals and Grievance experience with Managed Care Plans
Good typing and letter writing skills
Excellent written and oral communication skills
Excellent research and analytical skills
Basic computer knowledge
Excellent customer service skills
Ability to work well with diverse groups of individuals
Utilizes effective communication and conflict management skills

Job Responsibility

Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests
Review and respond to complaints, grievances and appeals within the stated time frame for each request
Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations
Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health internal policies and procedures
Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs
Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary
Certify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures

Fulltime

Appeals and Grievance Specialist II

This position requires the ability to work independently researching and reviewi...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Associate Degree Preferred
Previous Appeals and Grievance experience with Managed Care Plans
Good typing and letter writing skills
Excellent written and oral communication skills
Excellent research and analytical skills
Basic computer knowledge
Excellent customer service skills
Ability to work well with diverse groups of individuals
Utilizes effective communication and conflict management skills

Job Responsibility

Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests
Review and respond to complaints, grievances and appeals within the stated time frame for each request
Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations
Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health internal policies and procedures
Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs
Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary
Certify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures

Fulltime

Appeals and Grievances Nurse Specialist RN II

The Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provi...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of experience in Clinical RN
At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
Excellent interpersonal and communication skills
Computer literacy and adaptability to computer learning
Time management and priority setting skills
Must be organized and a team player
Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies
Good working knowledge of regulatory requirements/standards
Registered Nurse (RN) - Active, current and unrestricted California License

Job Responsibility

Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department
Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements
Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA)
Identification of Expedited Cases and resolution within 72 hours
Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation
Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE)
Process the case thru to effectuation and final case documentation in the A&G system of record
Investigation and preparation of State Fair Hearing cases as assigned
Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE)
Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status
Generates approval, modification and denial communications, to include member and provider notification of referral determination
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps
Follows up with caller to provide response or resolution steps

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Clinical Specialist, Quality Management I

Who We Are: Because health is personal. That's why Personify Health created the ...

Location

United States

Salary:

60600.00 - 91000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Active, unrestricted Registered Nurse (RN) license required
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Ability to work independently and utilize written resources to problem solve
After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations
Level I: In-depth knowledge of applicable regulations and accreditation standards (HIPAA, CMS requirements as applicable, NCQA, URAC)

Job Responsibility

Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable)
Conduct internal and external audits of UM/CM/CDM processes and documentation
prepare audit files, findings, and corrective action recommendations
Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution
Review and support SOPs and workflows to ensure regulatory alignment and operational clarity
Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance
Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows
Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions
Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners
Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Unlimited PTO—rest and recharge time is non-negotiable
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact on people's health

Fulltime

Product Manager – Operations & Regulatory

Beazley’s data reflects the complexity of our business. We are committed to buil...

Location

United Kingdom , Birmingham

Salary:

Not provided

Social Value Portal Ltd

Expiration Date

Until further notice

Requirements

Ability to define and drive data product strategy aligned with business objectives
Experience in designing and operationalising data policies, principles, and strategic frameworks
Strong understanding of relevant insurance / data domain
Experience in influencing and aligning senior leaders across business and technology
Proven track record of leading high performing data product teams
Degree in Data Science, Computer Science, Business Analytics, or related field
advanced degree desirable
Demonstrable experience of data product management or analytics product leadership within insurance or financial services
proven delivery at scale
Domain Expertise: Strong understanding of the specialist area (Ops/Reg, Dist/Marketing, or Policy/Claims) and adjacent functions (pricing, risk, finance)

Job Responsibility

Own product vision, domain strategy, portfolio roadmap, value outcomes, and cross-product alignment. Sets standards, prioritization criteria, and governance expectations. Accountable for adoption and benefits
Lead / Partner with Product Owners to translate strategy into prioritized backlogs, acceptance criteria, and release plans
Ensure delivery practices (Agile/Scrum/Kanban), NFRs (performance, governance, resilience, privacy-by-design), and control frameworks (quality, metadata, lineage) are embedded
Identify opportunities for data-driven innovation across the underwriting lifecycle including, claims, pricing, and customer engagement
Quantify and measure outcomes (e.g., loss ratio improvement, leakage reduction, campaign ROI uplift, cycle-time reduction)
Maintain product-level scorecards and dashboards tracking usage, quality, SLA performance, and business impact
Ensure partner deliverables meet standards, SLAs, and regulatory controls
participate in QBRs and corrective action plans
Maintain clear RACI and handoffs across build/run
Ensure clear RACI and handoffs across build/run between internal and partner teams

What we offer

Attractive base compensation and discretionary performance related annual bonus
Private medical insurance coverage for both you and your dependents
Company paid life assurance and long term disability insurance
Pension with 10% employer contribution, plus a further matched contribution up to 2.5%
25 days of annual leave (prorated for 1st calendar year of employment), plus public holidays, with the ability to flex the religious bank holidays to suit your religious beliefs, subject to approval. Additional annual leave purchase is also available up to a maximum of five additional days per year
Up to 2.5 days matched paid leave for volunteering at a charity of your choice and 5 days paid leave to provide or arrange care for a dependent with a long term care need annually
Up to £550 reimbursement towards home office setup
Free in-office lunch and monthly lifestyle allowance
Monthly travel allowance or annual season ticket
The opportunity to save for, and purchase, shares of Beazley stock

Fulltime

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Claims Resolution Specialist II

Job Description

Job Responsibility

Requirements

Nice to have

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