Medical Claims Analyst

7 days ago


Atlanta, Georgia, United States GeorgiaGov Full time
Job Summary

As a Nurse Investigator with the Georgia Department of Law, you will play a critical role in uncovering and preventing healthcare fraud within the Medicaid program. Under the direction of the Fraud Unit Director, you will assist in conducting thorough investigations by reviewing provider and recipient records, making determinations of medical necessity, and identifying potential areas of non-compliance.

Key Responsibilities
  • Maintain a comprehensive knowledge of the policies and procedures of the Georgia Medicaid Program.
  • Demonstrate thorough knowledge of and ensure compliance with departmental policies and procedures governing the Georgia Medicaid Program, as well as state and federal laws and policies governing Medicare and Medicaid.
  • Apply appropriate regulations, policies, and procedures to accurately determine reimbursable services and eligibility of providers as requested.
  • Assist prosecutors in Healthcare Fraud investigations by reviewing provider and patient records.
  • Make determinations of medical necessity, quality of services, and appropriateness of services rendered based on chart review and client interview and assessment.
  • Maintain a current repository of medically related information and departmental policies and procedures specific to the target groups reviewed.
  • Document non-compliance with Departmental, Federal and State policies and procedures and current standards and practices of medical documentation monitoring activities.
  • Reviews medical/clinical records for meeting criteria for authorized services.
  • Participate in investigations as a member of an interdisciplinary team.
  • Determine records to be reviewed.
  • Reviews records appropriate to each program and provider audited.
  • Determine program compliance and deficiencies according to established guidelines.
  • Provides immediate feedback to staff regarding any blatant compliance issues.
  • Accurately documents findings from audit on standard forms.
  • Participate in interviews of subjects and witnesses, and prepares written summaries of such interviews.
  • Prepares written reports of findings and opinions as directed by the prosecutor.
  • May testify as a witness in grand jury and trial court proceedings.
Requirements
  • Current RN license in the State of Georgia
  • Demonstrated experience in the analysis of Medicaid/Medicare claims
  • Preferred Qualifications:
    • Experience in one or more of the following:
    • Specific, additional experience in the analysis of medical services documentation and related claims
    • Utilization Review
    • Case Management
    • Analysis of CPT codes and/or ICD-10 Diagnosis Codes; and or
    • Medical Billing

  • Claims Fraud Analyst

    2 weeks ago


    Atlanta, Georgia, United States AIG Full time

    Claims Fraud AnalystAs a vital member of our Claims department, the Claims Fraud Analyst plays a crucial role in enhancing your expertise in the field of Claims.Impactful ContributionsThe Claims Fraud Analyst is tasked with overseeing all facets of the investigative process, which includes developing investigation strategies, pinpointing and delegating...

  • Senior Claims Analyst

    2 weeks ago


    Atlanta, Georgia, United States City of Atlanta Full time

    POSITION SUMMARY CLAIMS ANALYST - RISK MANAGEMENT DIVISIONThe City of Atlanta's Department of Law is in search of skilled candidates for the role of Claims Analyst within the Risk Management Division. This division is responsible for overseeing claims made against the City of Atlanta.Role Overview and Classification StandardsThe individual selected for this...

  • Senior Claims Analyst

    2 weeks ago


    Atlanta, Georgia, United States City of Atlanta Full time

    POSITION SUMMARY CLAIMS ANALYST - RISK MANAGEMENT DIVISIONThe City of Atlanta's Risk Management Division is in search of skilled candidates for a Senior Claims Analyst role. This division is responsible for overseeing claims made against the City of Atlanta.Role Overview and Classification StandardsThe individual selected for this role will provide...


  • Atlanta, Georgia, United States Walgreens Full time

    Job SummaryWe are seeking a highly skilled Specialty Billing Technician to join our team at Walgreens. As a key member of our revenue cycle team, you will be responsible for processing and managing medical claims, ensuring accurate and timely payment.Key Responsibilities:Process and manage medical claims, including reviewing and verifying patient...


  • Atlanta, Georgia, United States ICONMA Full time

    Position Overview:The Medical Liability Claims Specialist plays a crucial role in managing and resolving claims related to medical malpractice. This position requires a deep understanding of the complexities involved in liability claims and the ability to navigate the intricacies of medical malpractice insurance.Key Responsibilities:Utilize a Bachelor’s...


  • Atlanta, Georgia, United States AIG Full time

    At AIG, we are redefining how we assist clients in managing their risks. As a Claims Recovery Specialist, you will contribute to this evolution, enhancing your skills and experience as a vital member of our organization.Impacting the Claims ProcessOur Claims teams are recognized as the preferred problem solvers for clients, delivering consistent technical...


  • Atlanta, Georgia, United States AIG Full time

    About AIGAt AIG, we are transforming the way we assist clients in managing their risks. As a Claims Recovery Specialist, you will play a crucial role in this evolution, gaining valuable skills and experience as a key member of our team.Your Role in ClaimsOur Claims teams are recognized as the preferred problem solvers for clients, consistently delivering...


  • Atlanta, Georgia, United States AIG Full time

    At AIG, we are redefining the approach to risk management for our clients. As a Claims Recovery Specialist, you will contribute significantly to this evolution, enhancing your skills and experience as a vital member of our organization.Impact in Claims ManagementOur Claims teams are recognized as the preferred problem solvers for clients, consistently...


  • Atlanta, Georgia, United States MultiPlan Full time

    Imagine a workplace that empowers you to analyze, innovate, and motivate. Our team members excel by assisting healthcare payers in managing care costs, enhancing competitiveness, and driving positive transformation. You can be part of a well-established organization with a 40-year history dedicated to helping our clients succeed by assessing their needs and...

  • Claims Examiner

    1 day ago


    Atlanta, Georgia, United States Rose International Full time

    Job SummaryRose International is seeking a skilled Claims Examiner to join our team. As a Claims Examiner, you will be responsible for analyzing complex workers' compensation claims to determine benefits due. This role requires strong analytical and interpretive skills, as well as excellent oral and written communication skills.Key ResponsibilitiesAnalyze...

  • Claims Examiner

    1 month ago


    Atlanta, Georgia, United States American International Group Full time

    Make your mark in ClaimsOur Claims teams are the proven problem solvers of choice for clients, delivering consistent technical excellence and showcasing our service differentiation to create an unparalleled global claims handling experience. Through a robust stakeholder feedback loop and supported by consistent processes and leadership, we take pride in...


  • Atlanta, Georgia, United States AIG Full time

    OverviewAt AIG, we are redefining the approach to risk management. As a Senior Claims Specialist in the International Liability Division, you will play a crucial role in this evolution, enhancing your expertise and contributing significantly to our team.Your Role in International LiabilityOur Claims teams are recognized as the premier problem solvers for our...


  • Atlanta, Georgia, United States Marsh Full time

    Marsh is seeking candidates for our open Engagement Lead Consultant position. This is a hybrid role and will require 3 days in office and can be based in multiple locations. Marsh Consulting Solutions provides risk management consultation to global leaders in retail, healthcare, manufacturing, transportation, financial, and hospitality industries. Our...


  • Atlanta, Georgia, United States Careerbuilder-US Full time

    Position Overview:This role is for a skilled Claims Examiner with a strong background in evaluating insurance claims. We are looking for a professional who can effectively assess claims and ensure compliance with company policies and procedures. Key Responsibilities:Review and analyze claims to determine validity.Collaborate with various departments to...


  • Atlanta, Georgia, United States City of Atlanta Full time

    CLAIMS INVESTIGATOR - CLAIMS DIVISION The City of Atlanta Department of Law is in search of skilled candidates for the position of Claims Investigator within the Claims Division, which oversees claims lodged against the City of Atlanta. Position Overview and Classification Standards The individual selected for this role will be tasked with delivering...


  • Atlanta, Georgia, United States Hiscox Ltd Full time

    Job Type:PermanentBuild a brilliant future with HiscoxAbout Hiscox USA Hiscox USA underwrites small- to mid-market commercial risks through brokers, other insurers and distribution partners and directly to businesses. In 2023, gross written premiums for the segment will represent over $1bn. Circa 50% of the portfolio comprises small commercial business sold...


  • Atlanta, Georgia, United States Rose International Full time

    Job Title: Workers Compensation Claims ExaminerRose International is seeking a skilled Workers Compensation Claims Examiner to join our team. As a key member of our claims management team, you will play a critical role in analyzing and managing workers compensation claims to ensure timely and accurate benefits are provided to our clients.Key...


  • Atlanta, Georgia, United States Medix Full time

    Job SummaryWe are seeking a highly skilled and detail-oriented Claims Support Specialist to join our team at Medix. As a Claims Support Specialist, you will play a critical role in ensuring a quality patient experience within our service level agreements.The Claims Support Specialist will serve as a liaison between plan members, providers, and health...


  • Atlanta, Georgia, United States Careerbuilder-US Full time

    Position Overview:This role is for a skilled Claims Examiner with a strong background in evaluating and processing insurance claims. The position is a contract opportunity with the potential for long-term engagement. The role allows for remote work, providing flexibility while contributing to a dynamic team. Key Responsibilities:Review and analyze insurance...

  • Financial Analyst

    7 days ago


    Atlanta, Georgia, United States GeorgiaGov Full time

    Job Summary:We are seeking a highly skilled Financial Analyst to join our team at GeorgiaGov. As a Financial Analyst, you will play a critical role in performing professional-level finance, accounting, and fiscal control functions.Key Responsibilities:Update project information in our project management application.Analyze documentation and verify data to...