Medical Claim Analyst Jobs

Medical Claim Analyst — TX - Work from home. Apply via Workday.

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Waste & Error Certified Coding Manager is responsible for leading the Certified Coding Analyst and W&E Team Lead roles that conduct medical claim reviews and coding audits to identify billing errors, waste, abuse, fraud, and payment integrity opportunities. The Manager provides direct people leadership, establishes operational priorities, ensures consistent application of coding and billing requirements, and is accountable for team productivity, quality, service levels, compliance, and employee development. This role partners closely with the W&E team lead, who provides day-to-day technical guidance and subject matter support to the coding team. The Manager retains accountability for staffing, performance management, workload oversight, escalations, audit readiness, process improvement, and delivery of business outcomes. The position also represents the team in discussions with senior leadership, Medical Directors, Legal, Compliance, Analytics, Operations, and other Payment Integrity partners. Primary Responsibilities People Leadership & Team Development Lead, coach, and develop a team of Certified Coding Analysts and Senior Certified Coding Analysts. Establish clear role expectations, performance goals, productivity standards, quality requirements, and accountability measures. Conduct regular perfor

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The growing DSNP business has created an opportunity for an individual with claims experience, who is familiar with the 837 standard claims format. This individual will own 837 file transmissions to the states, manage and act on state response files, ensuring that all transactions transmitted are complete and error free. Manage and complete error corrections to meet state requirements. Required Qualifications 1&#43; year of experience with encounter data, medical claims, or Medicare/Medicaid. 1&#43; year of experience using FTP and data transfer software. 1&#43; year of data management experience. Preferred Qualifications Experience with Microsoft Access Databases. Analytical skills with the ability to identify and resolve data discrepancies. Working knowledge of the 837 claims files. Education Bachelors degree or equivalent work experience Anticipated Weekly Hours 40 Time Type Full time Pay Range <p s

JOB DESCRIPTION: Abbott is a global healthcare leader, creating breakthrough science to improve people’s health. We’re always looking towards the future, anticipating changes in medical science and technology. Our rapid diagnostics solutions are helping address some of the world’s greatest healthcare challenges. The Opportunity As the Finance Manager, SEA, you will be responsible for consolidating and reporting sales, P&L, and balance sheet results (actuals and forecasts) across Southeast Asia. You will partner closely with business leaders, support day-to-day finance operations, provide financial reporting and analysis, and ensure compliance with corporate financial policies and procedures. What You’ll Do Consolidate/Report for Sales and P&L and Balance Sheet (actual and forecast) for ID SEA: (Singapore, Malaysia, Vietnam, Thailand, Philippines, Indonesia, Cambodia, Laos, Vietnam) for Actual, RLBE/Forecast and Confirmation. Working closely with CM/GM as a strong Finance business partners and supports day to day business operations issues. Ensure completion of month end/year end closing with SSO / CFS team. Work along closely with SSO / CFS team on actual reporting, credit control, payment and all operations matters. Consolidate/Report/Monitor Cash Conversion Cycle, and Credit Management for SEA markets Distributors management: renewal/appointment process, inventory management, credit/margin claims processes, etc. Reporting and tracking of end-customer sales: (primary, secondary, inventory) across SEA markets Financial Analysis / Decision Support – Consolidate to understand the key drivers of profitability issues relating to any given Plan or RLBE cycl

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. Additional Responsibilities - Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication. - Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures. - Identifies and reports potential overpayments, underpayments, and other claim irregularities. - Performs claim rework calculations as needed. - Trains and mentors as needed to enhance team performance and technical proficiency. - Conducts outbound calls to obtain required information for claims or reconsideration requests. Required Qualifications - Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator. - Proven

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems. Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Performs claim re-work calculations. Follow through completion of claim overpayments, underpayments, and any other irregularities. Process complex non-routine Provider Refunds and Returned Checks. Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures. Review and handle relevant correspondences assigned to the team that may result in adj

ABOUT US Nestem Technologies is ISO 9001:2008 Certified and Govt Registered Leading Healthcare BPO Service Provider. Medical Coding and Billing Job offered For US Healthcare BPO. MEDICAL BILLING Medical Billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government sponsored programs Self Supportive Training will be provided for Freshers with Placement. BILLING INDUSTRY Employment is expected to grow faster than average. Job prospects is very good; persons with a strong background in medical billing and coding will be particularly high demand. PLACEMENTS & PAY DETAILS FOR TRAINED After successful completion of the Training job offer will be provided in Leading MNC's. Placements will be in Chennai. 9000/- to 12000/- PM initially with assured career growth (Excluding Special Allowances & Other Benefits). For further Information Call us on 979 1196 983 / 044-2481 4757.

ABOUT US Nestem Technologies is ISO 9001:2008 Certified and Govt Registered Leading Healthcare BPO Service Provider. Medical Coding and Billing Job offered For US Healthcare BPO. MEDICAL BILLING Medical Billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government sponsored programs Self Supportive Training will be provided for Freshers with Placement. PLACEMENTS & PAY DETAILS FOR TRAINED After successful completion of the Training job offer will be provided in Leading MNC's. Placements will be in Chennai. 9500/- to 12000/- PM initially with assured career growth (Excluding Special Allowances & Other Benefits). For further Information Call us on 9791196983

Job Title Senior Clinical Development Scientist, Ultrasound &EI Job Description In this role, you have the opportunity to Be a member of the medical and clinical affairs team in Greater China. Medical and Clinical affairs team is an integral part of global Chief Medical Office. The Clinical Development Scientist is responsible for executing evidence-generation processes, clinical development and market access strategies for New Product Introduction (NPI) projects and post-market activities. The role is responsible for analyzing clinical trial protocols and studies, ensuring alignment with regulatory standards and business objectives, and contributes to the study designs. The role drafts comprehensive Clinical Evaluation Reports (CERs), Clinical Study Reports (CSRs), and regulatory submissions, ensuring accuracy and compliance with regulatory requirements. The role maintains data integrity and accuracy throughout studies and performs rigorous literature searches and critical reviews to support evidence-generation processes, providing insights for strategic decision-making. You are responsible for Assesses clinical trial protocols and studies, ensuring alignment with regulatory standards and business objectives, and contributing to the development and refinement of study designs as needed, working under direct supervision. Executes clinical development and market access strategies for assigned New Product Introduction (NPI) projects and post-market activities, integrating inputs from stakeholders such as Marketing/BU Claims, regional/market needs, Health Economics, Market Access, and Post Market Surveillance (PMS). Crafts comprehensive and compliant Clinical Evaluation Reports (CERs), Clinical Study Reports (CSRs), and clinical sections of regulatory submissions, employing meticulous attention to detail and adherence to regulatory standards.<

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. This is a full-time telework position requiring 50-75% travel in the Metro East Regional counties, Illinois (Madison, St. Clair, Monroe, Clinton, Jersey, Calhoun, Macoupin, and Bond counties.) Hours for this position are Monday-Friday 8:00a-5:00pm Central Time. Position Summary The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process. The Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources. • Evaluation of Members: Through the use of care management tools and information/data review, conducts comprehensive evaluation of member’s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services. • Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. • Coordinates and implements assigned care plan activities and monitors care plan progress. • Enhancement of Medical Appropriateness and Quality of Care: Using holistic approach con

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary As the Senior Lead Coordinator you will be responsible for implementing and maintaining comprehensive billing review processes. You will identify and quantify trends/issues and effectively communicate/report them to the appropriate members of the management team and payer business partners along with the potential impact. You will assist leadership in building and maintaining a high performing highly engaged team. In this role you will also provide excellent mentorship and support to your colleagues as well as design and implement training classes. The key responsibilities of the Medical Revenue Cycle Senior Lead Coordinator are: Review and analyze patient profiles, benefits, and prior authorizations to identify potential issues affecting clean claims. Collaborate with clinical and administrative teams to ensure accurate documentation is maintained and available for claims processing. Monitor claims submissions and follow up on pending claims to expedite resolution and payment. Identify trends in claims denials and develop strategies for improvement. Conduct training sessions for staff on best practices for claims submissions and compliance. Maintain up-to-date knowledge of insurance policies, regulations, and healthcare trends that impact claims

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Aetna Better Health is Aetna’s Medicaid managed care plan. Backed by over 30 years of experience managing the care of those with a broad array of health care needs, our Medicaid plans have demonstrated that getting the right help when you need it is essential to better health. That’s why Aetna® Medicaid plans include the guidance and support needed to connect our members with the right coverage, resources, and care. We are focused on enhancing quality and population health outcomes while integrating CVS assets to bring accessible healthcare to our members. Aetna Better Health of Maryland is seeking an experience leader with vast operational knowledge of Medicaid for its state-wide managed Medicaid business in the role of Chief Operations Officer (COO). The COO role will be strategic and committed to developing colleagues as well as relentlessly pursuing change that is best for the organization and its customers. The COO role will collaborate with the CEO to develop the strategic vision of the Health Plan, policies & procedures, and operational objectives including leading RFP readiness efforts. The COO will oversee high level strategic and operational activities of various plan functional areas which include traditional service operations (Claims, Provider Services, Information Technology, Grievance & Appeals and Member Services) as well as Medical Management (Quality, Netw

Work Flexibility: Remote Staff Regulatory Affairs Specialist, Mako and Enabling Technologies (Remote) Join Stryker’s Ortho Tech Business and support a portfolio that spans robotics, navigation, imaging, software, and capital equipment technologies. In this role, you will provide regulatory leadership throughout the product lifecycle, partnering with cross-functional teams to support global product development, regulatory submissions, market access, and ongoing regulatory compliance across U.S. and international markets. Work Flexibility: This is a remote position, with a preference for candidates located in the U.S. Eastern Time Zone What You Will Do Develop and execute global regulatory strategies for new products, product changes, and lifecycle management activities. Participate in product development teams to ensure U.S., European, and international regulatory requirements are incorporated throughout all development phases. Evaluate product classifications, regulatory pathways, and jurisdictional requirements for medical devices and related technologies. Author and submit regulatory filings, including FDA submissions, international registrations, and supporting documentation required for product approvals. Review quality, preclinical, and clinical documentation to ensure submission readiness and regulatory compliance. Partner with global regulatory affiliates to support registrations, market expansions, and post-market regulatory activities. Lead interactions with regulatory authorities and notified bodies, including preparation of responses, submissions, and agency communications. Review product labeling, marketing materials, and product claims for compliance with applicable regulatory requirements and mentor junior regulatory team members on regulatory