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

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

People Operations Specialist II, I-9 Compliance

The primary and immediate focus of this role will be I-9 outbound appointments a...

Location

United States

Salary:

30.70 - 46.05 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Typically requires 2 years of experience in Human Resources (or 6 years in customer service)
Previous experience with hiring/onboarding new hires is a plus
Bachelor’s degree in business, Human Resources, Compliance, or Technology related field or equivalent experience
Attentive listening skills with the ability to ask probing questions to aid in problem solving and issue escalation
Ability to work effectively in high-pressure situations that require sound decision making and may involve confidential or sensitive matters
High sense of urgency for meeting commitments and completing assignments
Demonstrate knowledge and understanding of relevant HR content areas including but not limited to: payroll, leave, compliance, compensation, data management, benefits, onboarding, and core HR operations
Critical thinking and multi-tasking in a high-volume environment
Ability to consistently deliver high quality customer service in a professional manner
Excellent decision making, critical thinking, communication, presentation, and interpersonal skills. Ability to build/foster strong trusting relationships, influence leaders and develop solutions to achieve results

Job Responsibility

Handling the I-9 process for new hires in a timely and customer-focused manner
Meeting federal guidelines with the I-9 process
Scheduling and completing I-9 appointments with new hires
Ensure all documentation is completed with accuracy
Identify process improvement opportunities and participate in knowledge management efforts such as SOP updates, case documentation, and training content
Participate in cross-training in multiple content areas to support business continuity and enhance team agility
Monitor case queues, prioritize workload, and follow through on open items to drive resolution and accountability
Deliver a high-quality teammate experience by providing professional, empathetic and solution-oriented support
Partner with internal teams such as HR Business Partners, Centers of Excellence, and Payroll to ensure seamless end-to-end service delivery
Interpret and apply HR policies, procedures, and workflows across assigned cases, ensuring consistent and accurate execution

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Care Management Specialist II, D-SNP Team

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

Associate's Degree in Nursing for Registered Nurses OR 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
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

Job Responsibility

Utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines
Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases
Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner
Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit
Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team
Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) 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
Uses claims processing and care management software to look up member information, document contacts, and track member progress
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

What we offer

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

Fulltime

New

Coverage Counsel

GEICO is seeking a Coverage Counsel to join its Enterprise Litigation and Invest...

Location

United States , Chevy Chase; New York; Cleveland; Chicago

Salary:

118900.00 - 235750.00 USD / Year

Geico

Expiration Date

Until further notice

Requirements

Juris Doctor (JD) degree from an accredited law school
Admission to practice law in at least one U.S. jurisdiction
3–7 years of substantive experience in coverage litigation, including direct involvement in coverage disputes, declaratory judgment actions, and related insurance litigation
Proven track record of managing complex coverage matters, including bad faith and extra-contractual claims
Strong analytical, problem-solving, and decision-making skills
Excellent written and verbal communication skills, with the ability to explain complex coverage concepts to claims professionals and non-lawyers
Experience conducting factual and legal research, drafting coverage opinions, and preparing litigation documents

Job Responsibility

Advise the claims organization on coverage issues, including interpretation of policy language and application to specific claims
Manage and litigate coverage disputes, including declaratory judgment actions and appeals
Provide legal guidance on bad faith and extra-contractual allegations related to coverage matters
Conduct factual and legal research, draft coverage opinions, and develop in-house presentations on coverage topics
Review documents and provide recommendations to Legal Department management

What we offer

Comprehensive Total Rewards program that offers personalized coverage tailor-made for you and your family’s overall well-being
Financial benefits including market-competitive compensation
a 401K savings plan vested from day one that offers a 6% match
performance and recognition-based incentives
and tuition assistance
Access to additional benefits like mental healthcare as well as fertility and adoption assistance
Supports flexibility- We provide workplace flexibility as well as our GEICO Flex program, which offers the ability to work from anywhere in the US for up to four weeks per year

Fulltime

New

Retail display installer

2020 Companies seeks a reliable, detail-oriented, and self-motivated Field Servi...

Location

United States , Springfield

Salary:

17.10 USD / Hour

2020 Companies, Inc

Expiration Date

Until further notice

Requirements

Must be 18 or older (due to insurance requirements)
Must be authorized to work in the United States
Flexible availability Monday through Friday
Weekend and holiday availability as needed
Early morning and late-night availability as needed
Maintain a minimum of 20 hours of fieldwork within a rolling 30-day period
Climb a ladder up to 10 feet in height
Safely lift and carry up to 60lbs
Able to kneel, walk, crouch, bend over, handle/grasp, and reach overhead
Ability to adjust to the ever-changing variety of tasks and work environments

Job Responsibility

Installing and building displays, end caps, and fixturing
Maintaining and updating displays according to planograms/ client requests
Conducting break-fix repairs
Installing and updating sales floor fixtures and endcaps
Performing build-outs, resets, and display repairs
Following plan-o-grams and client-specific directives
Work independently, meet deadlines, and use mobile applications and technology to complete assignments
Manage store-level relationships
Ensure top-quality execution on every project
Respond and remain responsible for consistent communication with field services management quickly (within 24 hours of contact)

What we offer

Paid drive time and mileage reimbursement
Paid training
Job assignments include both flexible self-scheduling options and fixed shifts based on availability
Variety of projects and clients
Next-day pay on demand with DailyPay

Parttime

New

Account Manager

We're an iconic Aussie brand with a global footprint. Our purpose is to build a ...

Location

Australia , Wagga Wagga

Salary:

Not provided

Telstra

Expiration Date

February 26, 2026

Requirements

An excellent communicator with strong interpersonal, engagement and presentation skills who can present to the executives or the willingness to learn these skills
Strategic thinking with the ability to adapt to change
Able to make impact on the TBTCs performance and team engagement and culture
Demonstrated commitment to relationship building and working in partnership with key stakeholders is desirable

Job Responsibility

Take ownership for managing relevant customer relationships to support ongoing development, drive customer satisfaction and achieve revenue and sales objectives for the defined portfolio
Contribute to implementing the segment and portfolio strategy with a strong emphasis on outbound campaigns to win back and acquire new customers
Take accountability for managing inbound/outbound customer sales and service contracts, exploring sales opportunities, responding to queries and escalating complaints and leads to more experienced team members as required, to ensure timely remediation and positive customer experiences
Authentically collaborate with peers, team members and key stakeholders across the TBTC channel (e.g. Field Sales Team and internal Telstra team and partners) to support the identification and qualification of leads
Participate in customer initiatives such as developing and maintaining relevant account and portfolio plans that support ongoing relationship development and contribute to the achievement of financial and customer targets (revenue, profitability, NPS) & exceptional customer data quality
Meet individual and team sales and performance KPIs with a focus on acquisition metrics
Continue to upskill and develop capability and knowledge across Telstra’s portfolio of products and business solutions
Identify areas of improvement and actively embrace change and technology to better support our business customers

What we offer

Performance-related pay
Access to thousands of learning programs so you can level-up
Purchased annual leave scheme
Additional Telstra day off
Additional 30% off Telstra products and services
Toolkit provided (laptop + mobile phone + plan paid for)

Fulltime

!

New

Construction Materials Technician

We are currently seeking a Construction Material Technician to join our team at ...

Location

Ireland , Aughnacliffe, Co. Longford

Salary:

Not provided

Breedon Group plc

Expiration Date

March 06, 2026

Requirements

Good level of literacy & numeracy
Experience of working in a team environment, providing information and support to colleagues
Ability to be flexible in working hours, working night shifts or weekends if required
Computer literacy, knowledge of Microsoft Office suite including Excel
Driving licence to enable the post holder to fulfil the duties of the role
Ability to carry out sampling of aggregates, concrete and asphalt, which involves manual handling and working in an outdoor operational environment.

Job Responsibility

Test and sample aggregate, bituminous and unbound and earthworks materials including grading analysis, binder content and physical, chemical and mechanical testing in a safe and efficient manner, both in the laboratory and on contracting sites/plant
Conduct daily organoleptic checks for lab, production facilities and all stockpiles
Maintain a safe and tidy workspace and ensure the efficient running of the laboratory
Maintain quality standards by following Company and accrediting bodies quality procedures and protocol
Record sample details on test record sheets and laboratory software
Calibrate all testing equipment
Prepare for inspections from independent accrediting bodies
Undertake daily laboratory equipment checks
Investigate all material related complaints & provide suitable & sufficient feedback & evidence to support
Assist operational staff in daily quarry and depot activities

What we offer

35 per year days' annual leave days (inclusive of Bank Holidays)
Company pension scheme
Life Assurance Scheme
1 day per year to volunteer with a charity of your choice (fully paid!) and fund-matching up to €200 for charitable events
Make a Material Difference Awards
Employee Assistance Programme providing a wide range of health and wellbeing support 24/7
Option to participate in our ShareSave scheme
Access to our employee benefits platform, giving you discounts on a wide variety of high street shops and brands
Cycle to work with our Bike to work scheme
Broad learning opportunities, training, and career progression pathways.

Fulltime

New

District Support Pharmacist

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Enfield

Salary:

60.00 - 76.00 USD / Hour

CVS Health

Expiration Date

April 09, 2026

Requirements

Active Pharmacist License in the state where the Store is located
Active National Provider Identifier (NPI)
Not on the DEA Excluded Parties list
Ability to travel within a reasonable radius to support market staffing as business needs require
Regular and predictable attendance, including nights and weekends
Ability to complete required training within designated timeframe
Attention and Focus: Ability to concentrate on a task over a period of time
Ability to pivot quickly from one task to another to meet patient and business needs
Ability to confirm prescription information and label accuracy, ensuring patient safety
Customer Service and Team Orientation: Actively look for ways to help people, and do so in a friendly manner

Job Responsibility

Traveling the district to fill pharmacist shifts as scheduled by the District Performance Coordinator (DPC)
overseeing the pharmacy and serving as the Pharmacy Manager’s proxy during bench shifts without overlap
Supporting safe and accurate prescription fulfillment by following—and directing the pharmacy team to follow—pharmacy workflow procedures and utilizing the safety guardrails at every workstation
Assumes Pharmacy Manager’s day-to-day duties when serving as the only or the primary pharmacist-on-duty
Contributing to positive patient experiences by showing empathy and genuine care and coaching the pharmacy team to do the same: demonstrating compassionate care, collaborating with the patient’s total healthcare team, and proactively resolving insurance and/or medication issues
Proactively offering and delivering immunizations to keep patients healthy
engaging and supporting Pharmacy Technicians to learn to immunize
Supporting the effective management of pharmacy inventory in all pharmacies worked by following—and guiding the pharmacy team to follow—all inventory best practices, with a special focus on protecting cold chain products for our patients and our business
Remaining flexible for both scheduling and business needs, while contributing to a safe, inclusive, and engaging team dynamic
Maintaining relevant clinical and technical skills for the job as the industry evolves (including but not limited to company-required trainings and CMEs)

What we offer

Affordable medical plan options
a 401(k) plan (including matching company contributions)
an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Parttime

Claims Resolution Specialist II

Baptist Health (Florida)

Location:
United States , Jacksonville

Category:
Finance

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 20, 2026

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