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Collaborates with Claims, Operations, IT, Vendor Management, Vendor Compliance and the Vendor Delegation Oversight Sub-committee to ensure regulatory requirements are met by delegates and FDRs.
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Analyze healthcare data, including claims data, electronic health records/ electronic medical records (EHR/EMR), registries, and physician/patient surveys, to assess treatment effectiveness, cost-effectiveness, and patient outcomes.
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Participating in indirect tax projects, including sales and use tax refund claims. Participating in indirect tax projects, including sales and use tax refund claims. ACT Consulting has an immediate need for a State and Local Transaction Tax Accountant located in New York, NY with our direct client.
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Partner with and collaborate across functions on analytics and strategic initiatives, including, but not limited to, Underwriting, Actuarial, Reinsurance, Claims, and Operations. Experience with and exposure to various operational disciplines (underwriting, claims, IT, etc.
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Experienced in several of the following domains: biomedical informatics, outcomes and health services research, clinical trials, clinical decision support, population health and claims analytics, quality metrics and reporting, data security, privacy and regulatory compliance, and data governance.
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MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
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Qualifications Estimating knowledge using CoreLogic and/or Xactimate is required, along with the ability to navigate within Corelogic suites and guidewire claims handling platforms. Collaborates and consults with our Inland Marine/Builders Risk Underwriting and Engineering partners to determine liability and identify risk conditions to drive continuous improvement toward claims handling and risk management excellence.
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With 98% of cyber insurance claims in the past five years coming from small and mid-size businesses with revenue under $2B, providing an integrated solution to help manage risk is more critical than ever.
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EDI Software Developer (BizTalk)
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Conduct a thorough investigation of all claims and retain outside surveyors, adjusters, experts, defense counsel, coverage counsel, as needed, based on the severity of the claim, and the facts presented.
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Demonstrated knowledge of SAP/OPUS, claims, supply chains, Customs & Border Patrol (CBP) and compliance/FMC/PGA s. · Evaluate and process insurance claims if required. Demonstrated knowledge of SAP/OPUS, claims, supply chains, Customs & Border Patrol (CBP) and compliance/FMC/PGA s.
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Reviews and analyzes Physician/Allied Health/GME applications for initial appointment and reappointment and credentialing documents including clinical education/training, board certification and eligibility, licensure, accreditation, work history, liability insurance and malpractice claims history.
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Support reinsurance claims recovery process, providing on-going reporting to Group, responding to inquiries, and collaborating with other teams to ensure accurate reporting and recoveries are received in a timely manner from reinsurers and state catastrophe funds.
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Initiates and perform audits and monitoring activities of various health plan operations, such as appeals and grievances, claims, medical management, customer service, provider relations and contracting, sales and enrollment, and other functions to ensure proper compliance with governmental regulations and health plan policies.
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Works daily Accounts Receivable accounts via online work file and/or hard-copy reports; checks claims status, re-submits claims, and writes appeal letters. 3+ years of experience in medical billing or health claims, with experience in billing systems in a health care or insurance environment, and familiarity with ICD/CPT coding.
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claims adjudication jobs Company: Metroplus Health Plan in Flushing, NY
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