Medical Claims Manager

4 months ago


Coral Gables, United States PayerFusion Full time

Medical Claims Manager

We are looking for a Claims Manager that supervises and manages day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with agreed quality and production standards. Process claims in a timely manner and complies with industry fair claims practices and applicable state regulations concerning the processing of claims. Sets goals, while being accountable for the results. Manages staff of claims professionals, includes claims examiners, including the regular and timely evaluation of their performance. Maintains good, professional working relationship with superiors, peers, subordinates and other department managers and personnel.

About Us:

We are a service-based company and as a licensed third-party administrator, we are seeking only top talent and experienced personnel in order to meet and exceed our client's expectations. We're an innovative company creating a unique experience for healthcare professionals. While many industry-wide solutions exist, nothing comes close to our ground-breaking approach.

Duties & Responsibility:

* Supervise the claims departments to ensure proper workflow is conducted. Monitor timelines and constantly communicate via e-mail with clients to follow up on claims handling.
* Oversee Claims Examiner Department Responsible for searching the various networks and direct contracts database to determine the appropriate network that a claim should be processed through in order to secure the greatest savings to ensure clients continue to benefit from PayerFusion cost containment efforts. Meets deadlines promised to clients for claims processing.
* Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum. Identify claims that should be audited by the Medical Team when the total charges exceed the pre-established PayerFusion criteria.
* Coordinate and liaise with other departmental Supervisors as needed to ensure the operational process is followed. Identifies claims where little or no discount is available so that PayerFusion may attempt negotiations on these claims.
* Implement new procedures for new line of business. Train and cross-train all staff member with the Claims Handling Process and miscellaneous.
* Review & perform periodic quality assessments of work being released to the clients. Prepare reports as required.
* Provide clients with daily, weekly and or monthly updates on claims.
* Train new staff, also cross train existing staff
* Keep staff current about company, department and organizational issues, in addition to claims eligibility issues or procedures. This will be done via regular departmental meetings, one-on one communications and distribution of written directives.
* Advise management of any issues raised by staff and suggest actions that will improve processing or resolve the issues. Notify management on eligibility issues.

Knowledge of medical claims coding, different medical specialties and medical services billed for payment by providers to insurance companies is a must.

Bonus Points:

* PayerFusion provides competitive compensation. Base compensation commences with experience, and knowledge of the claims administration industry.

Benefits

* Excellent health and dental insurance coverage
* Free vision, life and hospital gap insurance
* 12 paid holidays
* Paid Time Off
* 401K with company match up to 4%
* Salary range is commensurate with the experience of the candidate.



  • coral gables, United States Ascendant Insurance Solutions Full time

    Ascendant Commercial Insurance is a full-service Florida based insurance company, seeking Workers' Compensation Adjusters to join the Claims team. We are a fast growing, diverse company, offering a complete suite of benefits and competitive compensation package.Ascendant is looking for the next generation of industry professionals! If you’re looking for a...


  • Coral Gables, United States Ascendant Insurance Solutions Full time

    Ascendant Commercial Insurance is a full-service Florida based insurance company, seeking Workers' Compensation Adjusters to join the Claims team. We are a fast growing, diverse company, offering a complete suite of benefits and competitive compensation package.Ascendant is looking for the next generation of industry professionals! If you’re looking for a...


  • coral gables, United States Ascendant Insurance Solutions Full time

    Ascendant Commercial Insurance is a full-service Florida based insurance company, seeking Workers' Compensation Adjusters to join the Claims team. We are a fast growing, diverse company, offering a complete suite of benefits and competitive compensation package.Ascendant is looking for the next generation of industry professionals! If you’re looking for a...


  • Coral Gables, United States Ascendant Insurance Solutions Full time

    Ascendant Commercial Insurance is a full-service Florida based insurance company, seeking Workers' Compensation Adjusters to join the Claims team. We are a fast growing, diverse company, offering a complete suite of benefits and competitive compensation package.Ascendant is looking for the next generation of industry professionals! If you’re looking for a...

  • Medical Records Coder

    3 weeks ago


    Coral Gables, United States KIDZ Medical Services Full time

    SUMMARY: Billing Specialist performs diagnosis and procedural coding to individual patient health information for data retrieval, analysis, and claims processing.DUTIES AND RESPONSIBILITIES: Reviews the patient 's medical record for accurate and complete documentation prior to coding.Works closely with the physician coordinator regarding discrepancies found...

  • Medical Records Coder

    3 weeks ago


    Coral Gables, United States KIDZ Medical Services Full time

    SUMMARY: Billing Specialist performs diagnosis and procedural coding to individual patient health information for data retrieval, analysis, and claims processing.DUTIES AND RESPONSIBILITIES: Reviews the patient 's medical record for accurate and complete documentation prior to coding.Works closely with the physician coordinator regarding discrepancies found...


  • Coral Springs, Florida, United States MEDEX Analytic Services Full time

    About UsMEDEX Analytic Services is a leading provider of independent medical examinations, peer reviews, and radiology reviews for comprehensive medical and legal analysis of bodily injury claims. Our nationwide service enables clients to efficiently manage and analyze their medical claims.Career OpportunityWe are seeking highly motivated and dedicated...


  • Coral Gables, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    Position Is Not Remote Position Purposes: Evaluates and approves requested services using organizational policies or MCG screening criteria. Responsibilities: Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests. Reviews cases referred by the prior-authorization non-clinical...


  • Coral Gables, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    Position Is Not RemotePosition Purposes: Evaluates and approves requested services using organizational policies or MCG® screening criteria. Responsibilities:Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests. Reviews cases referred by the prior-authorization non-clinical...


  • Coral Gables, Florida, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    We are seeking a skilled Medical Management Coordinator RN to join our team at Doctors Healthcare Plans, Inc. As a key member of our Utilization Management department, you will play a critical role in evaluating and approving requested services using organizational policies or MCG screening criteria.Job Responsibilities:You will manage appropriate cases that...


  • Coral Gables, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    Position Is Not Remote Position Purposes: Evaluates and approves requested services using organizational policies or MCG® screening criteria. Responsibilities: Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests. Reviews cases referred by the prior-authorization...


  • Coral Springs, Florida, United States MEDEX Analytic Services Full time

    About Our Opportunity"Medex Analytic Services is a nationwide provider of medical review services, specializing in Independent Medical Examinations, Peer reviews and Radiology Reviews. We are seeking a skilled associate to join our Customer Service Department, assisting our clients in managing and analyzing their medical claims. A successful candidate should...


  • Coral Gables, Florida, United States USHEALTH Full time

    About Our CompanyUSHEALTH is a dynamic and fast-paced environment where making a difference matters. As a Sales Account Representative, you will have the opportunity to build sustainable relationships and trust with customer accounts through open and interactive communication.Your Typical Day:Sitting or standing for long periods of time.Working with...


  • Coral Gables, Florida, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    About the RoleWe are looking for a detail-oriented Provider Data Specialist to join our team at DOCTORS HEALTHCARE PLANS, INC. The successful candidate will be responsible for processing claims in the Zero Queue and maintaining provider contracts.Key Responsibilities:Claims processing in the Zero Queue Loading and maintaining non-par provider records...


  • Coral Gables, Florida, United States DOCTORS HEALTHCARE PLANS, INC. Full time

    **Job Summary:**We are seeking a highly skilled Medical Management Coordinator RN to join our team at Doctors Healthcare Plans, Inc. As a key member of our healthcare team, you will play a critical role in evaluating and approving requested services, ensuring that our members receive the highest quality care.**Responsibilities:Evaluate and approve requested...

  • Pre-Suit Attorney

    2 months ago


    coral gables, United States Blue Signal Search Full time

    Pre-Suit Attorney Our client, a reputable law firm specializing in property damage and personal injury cases, is seeking an experienced Pre-Suit Attorney to join their team. The firm operates across 30+ locations with nearly 100 attorneys dedicated to achieving optimal outcomes for clients by securing the maximum restitution. This role is ideal for a...

  • Trial Attorney

    3 weeks ago


    Coral Gables, United States Triumph Professional Staffing Full time

    Multi office Florida firm is is looking for an experienced Trial Attorney with 5+ years of litigation experience, preferably in construction litigation, commercial litigation, and first party property claims. The ideal candidate should have the ability to handle multi-party construction complex cases in state and federal court, attend hearings, depositions,...


  • Coral Gables, Florida, United States Pazos Law Group Pa Full time

    Key ResponsibilitiesConduct intake meetings with new clients to understand their needs and provide personalized service.Execute attorney-client contracts and communicate case status updates to clients.Manage a docket of cases according to office policy and ensure timely completion of tasks.Communicate daily with insurance companies regarding claim statuses...

  • HR Business Partner

    2 weeks ago


    Coral Gables, Florida, United States MasTec Full time

    Job DescriptionOverviewMasTec Communications Group is a leading national infrastructure construction company operating throughout the United States. With a strong commitment to supporting its employees, MasTec provides a dynamic work environment where individuals can thrive and grow.The Human Resources Coordinator plays a critical role in supporting multiple...


  • Coral Springs, Florida, United States PRIORITY MEDICAL CENTERS LLC Full time

    Company OverviewPRIORITY MEDICAL CENTERS LLC is a dynamic healthcare organization dedicated to providing exceptional patient care. Our team of professionals works together to deliver top-notch services, and we are seeking a skilled Medical Administrative Assistant to join our team.Job DescriptionThis position involves a variety of administrative tasks,...