Specialty Claims Adjuster Job at The Emerald Group Ltd, Search and Selection (London)

FEP Clinical Pharmacist

Provide utilization and drug interaction of drug therapies to include review of ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

3 years or more as a practicing pharmacist
3 years or more experience in the managed care pharmacy field
Doctor of Pharmacy (Pharm.D) degree
Active, current and unrestricted State of Arizona (a state in the United States) pharmacist license
Specialty certification in Medication Therapy Management (may obtain certification within 6 months of job entry)
Proficient in critical literature evaluation skills, including evidence-based medicine principles
Excellent problem-solving skills
Strong written and verbal communications
Strong PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones

Job Responsibility

Collaborate with FEP Management, FEP Operations, and FEP HEDIS to create clear communication to FEP members and/or network providers on medication therapy recommendations
Work in partnership with FEPDO and Pharmacy Management team
Regularly collaborate with other plan pharmacy reps and programs
Collaborate with FEP Management and HEDIS staff for targeted FEP ongoing initiatives
Act as a clinical resource to FEP internal staff regarding medication therapy
Evaluate medication related problems such as adverse events, therapeutic duplication, adherence to therapy, polypharmacy, and untreated disease or conditions
Analyzes, documents, and reports member outreach and intervention performance results as required by the FEP Medication Therapy Management Program (MTM Program)
Provide education and training on the appropriate use of medications to monitor and evaluate patient’s response to therapy
Document all interventions via a medication related action plan or care plan (CP)
Support and resolve pharmacy related member specific benefit issues

Fulltime

Medical Coding Reimbursement Review Specialist

We are seeking an experienced and detail-oriented Medical Coding Reimbursement R...

Location

United States

Salary:

21.42 USD / Hour

MMC Group LP

Expiration Date

Until further notice

Requirements

Certified Medical Coder certification required through recognized organizations such as AAPC or AHIMA
CPC (Certified Professional Coder) preferred
CCS (Certified Coding Specialist) preferred
Strong inpatient coding experience required
3-5 years of medical coding and reimbursement review experience preferred
Experience with CPT codes, ICD-10-CM, and HCPCS coding systems required
Strong understanding of CPT modifiers and reimbursement impact required
Experience with retrospective coding reviews required
IDRE experience required
Must be able to explain the IDR process during the interview

Job Responsibility

Perform retrospective payment reimbursement reviews with a strong focus on inpatient coding
Analyze CPT codes, modifiers, and claim interactions to ensure accurate reimbursement determinations
Review and interpret Explanations of Benefits (EOBs), including recoupments, corrections, denials, and claim adjustments
Evaluate how CPT modifiers impact reimbursement and payment outcomes
Conduct coding reviews across multiple provider specialties with broad CPT code knowledge
Review medical claims for compliance with coding standards and reimbursement guidelines
Prepare clear, accurate, and final binding payment determination letters for clients and disputing parties
Support Independent Dispute Resolution (IDR) cases and demonstrate knowledge of the full IDR process
Maintain compliance with billing regulations, coding standards, and applicable healthcare laws
Manage multiple priorities effectively while meeting strict deadlines in a high-volume environment

What we offer

Medical, dental, and vision coverage
Life and disability insurance
Additional voluntary benefits

Fulltime

Multi-Line Adjuster Trainee

We are looking for a highly motivated and service-oriented individual to join ou...

Location

United States , Syracuse, NY; Albany, NY; Buffalo, NY; Downstate NY

Salary:

Not provided

Geico

Expiration Date

Until further notice

Requirements

Valid driver’s license (must meet company underwriting guidelines for at least the past 3 consecutive years) and the ability to maintain applicable state and federal certifications and permits
Willingness to be flexible with primary work location – position may require either remote or field work
Solid computer, mechanical aptitude, and multi-tasking skills
Effective attention to detail and decision-making skills
Ability to effectively communicate, verbally and in writing, and willingness to expand on these abilities
Minimum of high school diploma or equivalent, college degree or currently pursuing preferred

Job Responsibility

inspecting damage
estimating cost of repairs
negotiating settlements
issuing payments
providing excellent customer service
servicing boat, motorcycle, RV and other specialty claims

What we offer

Comprehensive Total Rewards program
401K savings plan vested from day one that offers a 6% match
performance and recognition-based incentives
tuition assistance
access to additional benefits like mental healthcare as well as fertility and adoption assistance
workplace flexibility
GEICO Flex program, which offers the ability to work from anywhere in the US for up to four weeks per year

Fulltime

Multi-line Adjuster Trainee

We are looking for a highly motivated and service-oriented individual to join ou...

Location

United States , New York City; Syracuse; Albany; Buffalo; Rochester

Salary:

Not provided

Geico

Expiration Date

Until further notice

Requirements

Valid driver’s license (must meet company underwriting guidelines for at least the past 3 consecutive years) and the ability to maintain applicable state and federal certifications and permits
Willingness to be flexible with primary work location – position may require either remote or field work
Solid computer, mechanical aptitude, and multi-tasking skills
Effective attention to detail and decision-making skills
Ability to effectively communicate, verbally and in writing, and willingness to expand on these abilities
Minimum of high school diploma or equivalent, college degree or currently pursuing preferred

Job Responsibility

Inspecting damage
Estimating cost of repairs
Negotiating settlements
Issuing payments
Providing excellent customer service
Servicing boat, motorcycle, RV and other specialty claims

What we offer

Comprehensive Total Rewards program
401K savings plan vested from day one that offers a 6% match
Performance and recognition-based incentives
Tuition assistance
Access to additional benefits like mental healthcare as well as fertility and adoption assistance
Workplace flexibility
GEICO Flex program, which offers the ability to work from anywhere in the US for up to four weeks per year

Fulltime

Medical Peer Reviewer

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a c...

Location

United States

Salary:

122907.00 - 188020.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Board Certified in Internal Medicine, Family Practice, OBGYN, Emergency Medicine (Preferred)
Previous, relevant experience in utilization management and clinical practice (Preferred)
Knowledge of Medicare, Medicaid, and MLTC plans (Preferred)
Time management, critical thinking, communication, and problem-solving skills (Preferred)
Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies (Preferred)
Knowledge of member satisfaction/incident management and regulations (Preferred)
Knowledge of quality improvement methodologies (Preferred)
Ensures compliance to internal Healthfirst and external regulations

Job Responsibility

Assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations
Render determinations in the format and within timeframes to follow Regulatory and Operational policies
Maintain productivity standards
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software
Enter each day’s hours worked in Workday, on the same day
Perform other duties as assigned
Responsibilities may be adjusted based on changing needs of the organization

What we offer

Medical, dental and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Paid Time Off (PTO)
Holiday pay and straight hours worked for covering one legal holiday/year

Parttime

Medical Coding Review Specialist

We are seeking a highly motivated, detail-oriented Medical Coding Review Special...

Location

United States , Remote

Salary:

21.42 USD / Hour

MMC Group LP

Expiration Date

Until further notice

Requirements

Certified Medical Coder credential from a recognized organization such as AAPC, AHIMA, CPC, CCS
3 to 5 years of medical coding experience, preferably within reimbursement review, claims review, or retrospective coding environments
Strong experience with inpatient coding, CPT codes, CPT modifiers, retrospective coding reviews
Experience with IDRE and the ability to clearly explain the IDR process during the interview
Working knowledge of ICD-10-CM, CPT, HCPCS
Strong ability to read and interpret EOBs, claim adjustments, recoupments, and corrections
Excellent written communication skills, with the ability to draft professional and accurate determination letters
High attention to detail and commitment to accuracy and compliance
High School Diploma or GED required

Job Responsibility

Perform retrospective payment reimbursement reviews with a strong focus on coding accuracy and reimbursement analysis
Review and analyze inpatient coding scenarios, including CPT code application, modifiers, and reimbursement outcomes
Conduct retrospective coding reviews to ensure appropriate coding, billing accuracy, and payment determination support
Interpret and evaluate Explanations of Benefits, EOBs, including recoupments, corrections, denials, and other claim adjustments
Assess how CPT codes interact with one another and how modifiers impact reimbursement outcomes
Apply broad coding knowledge across multiple provider specialties
Support work related to the IDRE process, including accurate documentation and case review
Draft final and binding payment determination letters for distribution to clients and disputing parties
Maintain a high level of productivity, accuracy, and compliance in a deadline-sensitive environment

What we offer

Medical, dental, and vision coverage
Life and disability insurance
Additional voluntary benefits

Fulltime

Clinician Coding Liaison - General Surgery

This job description indicates the general nature and level of work expected of ...

Location

United States , Milwaukee

Salary:

35.50 - 53.25 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) certification, or Coding Specialist (CCS) certification, or Coding Specialist – Physician (CCS-P) certification issued by the American Health Information Management Association (AHIMA) or Professional Coder (CPC) certification issued by the American Academy of Professional Coders (AAPC)
Completion of advanced training through a recognized or accredited program, equivalent in scope and rigor to post-secondary education or equivalent knowledge
High school diploma or GED required
Typically requires 4 years of experience in expert-level professional coding
Advanced knowledge of ICD, CPT, and HCPCS coding guidelines
Strong understanding of medical terminology, anatomy, and physiology
Advanced knowledge of Epic and other reporting tools
Highly proficient in problem-solving and analytical thinking with strong attention to detail
Excellent verbal and written communication skills
Proficiency in Microsoft Office Suite, electronic coding applications, and email communication

Job Responsibility

Deliver proactive coding education through newsletters, scorecards, and presentations, covering CPT (E&M, modifiers), ICD-10-CM, HCPCS, Risk Adjustment, payer requirements, and rejection resolutions
Lead onboarding and compliance training for all employed Physicians/APPs, including Locum Tenens, residents, and students, ensuring documentation accuracy from the start
Provide individualized documentation feedback by reviewing new clinician records and conducting spot checks, escalating non-coding issues to appropriate teams
Serve as the primary contact for coding inquiries, coordinating with internal teams to resolve complex issues such as NCCI bundling and high-complexity charge edits
Monitor Epic work queues (charge review, follow-up, claim edit) to ensure timely and accurate charge submissions and reduce claim denials
Collaborate across departments—including CMOs, Clinical Informatics, Risk Adjustment, and Population Health—to enhance documentation practices and system optimization
Participate in specialty and department meetings, identifying trends and delivering targeted education to improve coding and documentation accuracy
Refine Epic documentation tools, including templates, order entries, diagnosis lists, and SmartSets/SmartPhrases, to improve efficiency and accuracy
Ensure compliance with regulatory standards, including Medicare, Medicaid, and AHIMA’s Standards of Ethical Coding, while maintaining expert knowledge of evolving policies
Promote a culture of ethical coding and continuous improvement, supporting clinicians with timely updates, feedback, and education to ensure accurate reimbursement and compliance

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
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Multi-Line Adjuster Trainee

We are looking for a highly motivated and service-oriented individual to join ou...

Location

United States , Fairfield

Salary:

Not provided

Geico

Expiration Date

Until further notice

Requirements

Valid driver’s license (must meet company underwriting guidelines for at least the past 3 consecutive years) and the ability to maintain applicable state and federal certifications and permits
Willingness to be flexible with primary work location – position may require either remote or field work
Solid computer, mechanical aptitude, and multi-tasking skills
Effective attention to detail and decision-making skills
Ability to effectively communicate, verbally and in writing, and willingness to expand on these abilities
Minimum of high school diploma or equivalent, college degree or currently pursuing preferred

Job Responsibility

inspecting damage
estimating cost of repairs
negotiating settlements
issuing payments
providing excellent customer service
servicing boat, motorcycle, RV and other specialty claims

What we offer

Comprehensive Total Rewards program
401K savings plan vested from day one that offers a 6% match
performance and recognition-based incentives
tuition assistance
mental healthcare
fertility and adoption assistance
workplace flexibility
GEICO Flex program, which offers the ability to work from anywhere in the US for up to four weeks per year

Fulltime

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Specialty Claims Adjuster

Job Description

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