Florida Blue

Role Description Leads a multi-disciplinary team to resolve authorization/referral requests and clinical claims and inquiries within regulatory and accreditation compliance standards. - Resolving clinical claims and inquiries to enhance member and provider experience and manage medical costs. - Ensures timely notification of authorization/medical review requests to members and providers, with explanations of appeal and peer-to-peer review request processes. - Educates providers regarding authorization and medical review processes to facilitate timely and appropriate decisions on behalf of members. - Collaborates with IT, Network, Availability, Clinical Enablement, Vendor Managers, Service Organization, and other areas of the company for optimal resolution of medical review requests. - Responsible for meeting and reporting operational metrics related to clinical review, including identification of trends, potential leakage, and opportunities for process improvements. - Leading the FEP/PEP Pre and Post-Service team to meet company goals, regulatory and legislative mandates, and operational objectives through standardized clinical processes. Qualifications - 5+ years related work experience. - 2+ years direct supervisory/management experience. - Related Bachelor’s degree or additional related equivalent work experience. - Occasional travel required (10% within the state of Florida). - Leadership skills (communicating, inspiring, empowering, resolving conflicts, etc). - Knowledge of general management practices (organizing, planning, controlling, budget/expenditure control, HR program/practices) in a participative environment. - Excellent written and verbal communication skills with the ability to communicate effectively with all levels of an organization and diverse audiences. - Proven ability to build relationships within the business area, across the organization, and external to BCBSF. - Proven ability to resolve issues and barriers. - Continuous improvement (CI) processes (Six Sigma or other TQM methodologies and tools). - Knowledge of and ability to coach on service tools, processes, and programs. - Health care regulatory requirements; excellence in customer service; knowledge of Microsoft Office including Outlook. Preferred Qualifications - Knowledge of CMCA, CCMS, Siebel. - Master’s degree or advanced degree in related field. - Active Florida RN license. General Physical Demands - Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. - Jobs are sedentary if traversing activities are required only occasionally. Benefits - Medical, dental, vision, life and global travel health insurance. - Income protection benefits: life insurance, short- and long-term disability programs. - Leave programs to support personal circumstances. - Retirement Savings Plan including employer match. - Paid time off, volunteer time off, 10 holidays and 2 well-being days. - Additional voluntary benefits available. - A comprehensive wellness program. Annualized Salary Range - $84,500 - $137,300. - Typical Annualized Hiring Range: $84,500 - $105,600. Equal Employment Opportunity We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

We are seeking a highly organized and proactive Administrative Assistant to provide direct support to Director and Senior Manager levels while collaborating across multiple teams in a remote environment. This role requires exceptional coordination, communication, and organizational skills, along with the ability to manage competing priorities with professionalism and discretion. The ideal candidate is resourceful, detail-oriented, and thrives in a fast-paced, virtual setting. Important to Know This is a full time remote position. You must reside in the State of Florida and be available to work Monday through Friday during Eastern Time Zone business hours. What Will You Be Doing - Provide administrative support to Directors and their staff - Coordinate conferences and meetings, maintain calendars and prepare materials such as presentations, spreadsheets and agendas - Receive, screen and handle telephone calls, incoming mail/email, publications and other correspondence, much of which is confidential or sensitive in nature - Process time and expense reporting - Interact effectively with individuals at all levels within and outside of the Company in a professional and confidential manner - Partner with multiple teams and stakeholders across the organization to support business initiatives - Create, maintain, and update spreadsheets and reports using Microsoft Excel - Utilize intermediate Excel functions including VLOOKUP, formulas, and data analysis to support reporting needs - Produce recurring and ad hoc reports that support leadership decision-making - Support special projects, reporting requests, and process improvements as needed - Handle confidential and sensitive information with a high degree of discretion What We Require - 2+ years related work experience preferably in supporting leaders with travel, calendar management, expense reporting, and preparing reports - High school diploma or GED - Proven experience working with Microsoft Office products: (Word, Excel or PowerPoint) General Physical Demands - Exerting up to 10 pounds of force occasionally to move objects. - Jobs are sedentary if traversing activities are required only occasionally. What We Offer As a Florida Blue employee, you will thrive in our culture working as a team serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, short- and long-term disability programs - Leave programs to support personal circumstances - Retirement Savings Plan including employer match - Paid time off, volunteer time off, 10 holidays and 2 well-being days - Additional voluntary benefits available; and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Hourly Targeted/Offer Pay Range: $20 - $25 Hourly Pay Range: $20 - $33 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. What is your impact? Utilization Management (UM) nurses will provide our clients with appropriate and comprehensive utilization of health care services and benefits as designated. This requires an experienced RN with a diverse clinical background, as well as experience within the managed care industry and specifically in the self-funded arena. The UM Nurse will work with providers, hospitals, members and clients to achieve optimal outcomes through appropriate use of services and benefits. What is your impact? - Pre-Certification of emergency, urgent and elective admissions, and the determination of length of stay based on age, multiple or single diagnoses, and the nature of the diagnosis. Medical record review to determine medical necessity of requested services. - Concurrent review and the determination of the extension of the length of stay based on the severity of illness and the intensity of service. Medical record review to determine medical necessity of requested services. - Assist with Discharge Planning to ensure compliance with benefit plan and use of preferred providers/networks. Steerage to high quality, cost-effective domestic and in-network providers. - Identification of alternative treatment plans, which are to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines allowing available claims dollars to be used in the most judicious manner possible (10%) - Establishing identification of services, resources, providers and facilities that could best serve clientele in a timely and cost- effective manner in order to obtain optimum value for the client and reimbursement source. - Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions. - Evaluate the cost effectiveness of the elected treatment plan, pre-implementation and post- implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans. - Referral to appropriate care management resources (i.e. Medical Director, Complex Case Management, and Chronic Condition Management teams). Qualifications - 5+ years related work experience. - Professional background in clinical nursing and patient assessment. - Graduate of an accredited school of nursing. RN - Registered Nurse - Compact State Licensure in good standing. - Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices. - Ability to collaborate with cross-operational areas within the organization. - Good verbal and written communication skills. - Ability to work as a team member, effectively and collaboratively, with non-clinical teammates. - Maintaining client's privacy, confidentiality and safety as well as acting as an advocate for the covered member. - Adherence to ethical, legal and accreditation/regulatory standards. - Bachelor’s degree in nursing preferred - Intensive care or higher-acuity patient experience preferred. - Prior experience in utilization management or case management preferred, preferably within the managed care environment. - Proficiency in maintaining good rapport with other staff members, physicians, health care facilities, clients, and providers. - Knowledge of managed care in a self-funded employer population is preferred. - Ability to identify problems such as underutilization or overutilization of services - Ability to promote and maintain quality care through analysis What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, short- and long-term disability programs - Leave programs to support personal circumstances. - Retirement Savings Plan includes employer contribution and employer match - Paid time off, volunteer time off, and 11 holidays - Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Physical/Environmental Activities Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. Key position details: - Anticipated Training Class Start Date: 5/25/2026 - Schedule Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. - Day-to-day processing of claims for accounts: - Responsible for processing of claims (medical, dental, vision, and mental health claims) - Claims processing and adjudication. - Claims research where applicable. - Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). - Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. - Investigation and overpayment administration: - Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. - Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. - Utilize systems to track complaints and resolutions. - Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: - 2+ years related work experience. - Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. - High school diploma or GED - Knowledge of CPT and ICD-9 coding required. - Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. - Must possess proven judgment, decision-making skills and the ability to analyze. - Ability to learn quickly and multitask. - Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. - Concise written and verbal communication skills required, including the ability to handle conflict. - Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. - Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: - Some college courses in related fields are a plus. - Other experience in processing all types of medical claims helpful. - Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, Short- and long-term disability programs - Flexible schedules after training - Leave programs to support personal circumstances. - Retirement Savings Plan includes employer contribution and employer match - Paid time off, volunteer time off, and 11 holidays - Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. Key position details: - Anticipated Training Class Start Date: 5/25/2026 - Schedule Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. - Day-to-day processing of claims for accounts: - Responsible for processing of claims (medical, dental, vision, and mental health claims) - Claims processing and adjudication. - Claims research where applicable. - Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). - Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. - Investigation and overpayment administration: - Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. - Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. - Utilize systems to track complaints and resolutions. - Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: - 2+ years related work experience. - Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. - High school diploma or GED - Knowledge of CPT and ICD-9 coding required. - Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. - Must possess proven judgment, decision-making skills and the ability to analyze. - Ability to learn quickly and multitask. - Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. - Concise written and verbal communication skills required, including the ability to handle conflict. - Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. - Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: - Some college courses in related fields are a plus. - Other experience in processing all types of medical claims helpful. - Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, Short- and long-term disability programs - Flexible schedules after training - Leave programs to support personal circumstances. - Retirement Savings Plan includes employer contribution and employer match - Paid time off, volunteer time off, and 11 holidays - Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Job Summary The work of a Sr. Coding & Coding Quality Educator relates to practices and principles associated with medical record auditing and utilizes various techniques in examining, evaluating and providing feedback and training to various stakeholders (certified coders, physician's practices, etc.) Key responsibilities include setting up a standard medical record auditing process and assisting in all matters relating to implementation of coding quality and coding training programs for Coders and Physicians, creating an integrated Program plan to carry out goals and managing/monitoring progress of the program execution. Essential Functions - The essential functions listed represent the major duties of this role, additional duties may be assigned. - Work closely with and coach certified coders and assist in assessing the strengths and weaknesses, ensuring that quality issues translate into timely training and ongoing coding reinforcement to the coders. - Verify, document and communicate quality audit results, develop audit reports and evaluate the effectiveness of corrective action plans and follow up. - Identify coding opportunities and make recommendations to improve internal controls and operational effectiveness and efficiency. - Assist in preparation & development of provider training tools and lead and conduct educational and training programs for physician training on various aspects of documentation and ICD-10-CM coding. - Perform review of specific provider/provider group medical records, develop audit reports and communicate audit results to external physician groups and physician group administration. - Coordinate quality audit program reporting and provider coding training with appropriate areas within Medicare Advantage Risk Adjustment and promote teamwork. - Responsible for the development and ongoing, end-to-end management of the quality audit program ensuring that QA activities and measurements are objective. - Responsible for quality audit program performance and adherence to established ICD-10-CM and CMS-HCC coding guidelines, ensuring compliance with all regulations. - Develop and maintain appropriate reporting, identifying metrics that will reflect true audit program performance. - Gain management concurrence and support for recommended control improvements. - Test and improve training program based upon experience and feedback. - Gather information, constantly update knowledge on various changes that are happening in the field of quality audit and modify coding guidelines to incorporate new knowledge. Share changes with coders as well as physician practices partners. - Manage multiple complex issues and projects simultaneously. - Work collaboratively with other areas of Revenue Program Management to identify, implement and monitor continuous improvement opportunities. - May require travel 0-25% of the time to Florida Blue office locations and provider engagements. Required Experience: 5+ years related work experience. Experience Details: Professional coding including proficiency in ICD-10-CM coding guidelines and risk adjustment HCC coding Related Bachelor’s degree or additional related equivalent work experience AAPC Certified Professional Medical Auditor (CPMA) certification AAPC Certified Professional Coding Instructor (CPC-I) certification 1 Year Knowledge of CMS-HCC risk adjustment data validation process. Organization and time management skills Demonstrate written and verbal communication skills. Preferred Qualifications: Knowledge of government regulations, requirements, and standards related to the management of health information. Knowledge of Scope and Statistical Sampling Methodologies Detail-oriented, commitment to accuracy, ability to problem solve. Working knowledge of MS Office (Excel, Word, PowerPoint) General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Physical/Environmental Activities Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally What We Offer: As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: - Medical, dental, vision, life and global travel health insurance; - Income protection benefits: life insurance, short- and long-term disability programs; - Leave programs to support personal circumstances; - Retirement Savings Plan including employer match; - Paid time off, volunteer time off, 10 holidays and 2 well-being days; - Additional voluntary benefits available; and - A comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Salary Range: $77,600 - $126,100 Typical Annualized Hiring Range: $77,600 - $97,000 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Job Summary The Sr. Digital Communications Manager is responsible for developing and managing an ongoing digital communications strategy for internal audiences. This position is accountable implementing and evaluating multiple complex initiatives, capabilities, and functions, and ensures strategy alignment with overall communications and corporate strategies. This position acts as a strategic digital communications consultant to Chief Communications Officer and senior leaders within Enterprise Communications and across the Enterprise, and establishes deep partnerships with key internal stakeholders across the business and IT organizations at all GuideWell companies and create cross functional processes that enable a consistent and connected experience for employees. Responsible for gaining alignment and driving change within assigned functions. Leads cross function initiatives and is relied upon to anticipate and mitigate cross functional issues. Ensures we're building a world-class and forward-leaning user experience, thoughtfully integrating proprietary and partnered solutions, supporting the evaluation and integration of the most important and exciting new technologies. Essential Functions: - The essential functions listed represent the major duties of this role, additional duties may be assigned. - Lead a multidisciplinary team to develop, implement, maintain and monitor digital communications solutions for Enterprise Communications on behalf of all wholly-owned GuideWell companies. Launch digital communication solutions with elements of technology and business. Act as administrator for multiple communication tools, leading the decision-making process for governance. - Drive build/buy/partner recommendations for digital product solutions, innovation and emerging communication technologies. - Develop and maintain a communications innovation strategy that enables the communications roadmap. - Responsible for communicating, planning, motivating and providing direction and leadership to functional resources within and outside of direct team. In a dynamic and fast-paced environment, be a leader that can motivate and inspire teams, creating a can-do culture of innovation. - Provide input, advice and consultation on multiple communication strategy and distribution decisions at all levels -- including executive communications. - Develop metrics and measure effectiveness of technology-based communication activities and use feedback to improve future performance. - Plan and lead technical aspects of executive meetings including Officers Meetings, Enterprise Leadership Meetings, and Pat’s Perspectives, working with IT as needed to produce professional quality meetings. Required Experience: 6+ years related work experience. Experience Details: Project management, digital platform management, system implementation and optimization experience. 3+ years direct supervisory/management experience Related Bachelor’s degree or additional related equivalent work experience Highly refined communication skills including ability to negotiate, build consensus, and clearly articulate to technical and non-technical audiences; able to communicate difficult messages in a professional and productive manner. Excellent presentation and facilitation competence. Demonstrated ability to lead technical and cross-functional teams through complex system implementation initiatives while dealing with change and meeting schedule and budget objectives. Deep, thorough understanding of business processes being supported. Excellent decision-making, problem-solving, organization, prioritization, team-building, conflict management and time management skills. Proven ability to innovate solutions in a complex matrix environment. Knowledge and understanding of technical systems/workflows and documentation. Knowledge of quality assurance, system and user acceptance testing. Experience in a high-volume multi-project environment with multiple stakeholders, including project, resource and vendor management experience. Professional presence, a positive and enthusiastic demeanor, and the ability to build relationships in a highly-matrixed environment. Strong project management skills with the ability to execute programs with speed, accuracy, and efficiency while coordinating/managing multiple high profile projects simultaneously. Demonstrated ability to write business requirements, and translate business requirements into technical design requirements to design solutions to meet business needs. Well organized, disciplined and process-oriented, able to set priorities and put actions in place to execute a communications/technical plan effectively. The ability to problem-solve, using investigative research and analytical skills to develop and implement creative solutions. Strong influencing, negotiating, decision-making, and relationship management skills. Preferred Education Preferred Qualifications: Deep experience using technology to achieve and drive improved business value and familiarity with emerging trends, technology, UX, and development tools and agile methodologies. Brings a high-energy and passionate outlook to the job and can influence those around them; Able to build a sense of trust and rapport that creates a comfortable and effective workplace. Strong knowledge of various digital communications and social media software and platforms, including content management systems and digital publishing tools. Knowledge and understanding of technical systems/workflows and documentation. Advanced knowledge of Microsoft SharePoint and Microsoft Tool Suite. Master’s degree General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. What We Offer: As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: - Medical, dental, vision, life and global travel health insurance; - Income protection benefits: life insurance, short- and long-term disability programs; - Leave programs to support personal circumstances; - Retirement Savings Plan including employer match; - Paid time off, volunteer time off, 10 holidays and 2 well-being days; - Additional voluntary benefits available; and - A comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Salary Range: $100,400 - $163,200 Typical Annualized Hiring Range: $100,400 - $125,500 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

The Senior Risk Adjustment Quality Auditor utilizes their expertise and industry standard coding guidelines in performing quality accuracy audits for both internal Companies Coders and external Vendors, Partners, and Provider Groups, ensuring the accuracy of ICD-10 coding and claims data for CMS/HHS risk adjustment data submissions. The Senior Risk Adjustment Quality Auditor shall assist Leadership with the quality audit processes, identify trends and opportunities for training and education. This position shall utilize critical thinking skills and effective communication to ensure coding compliance and oversight of same. Important to Know - Candidates that move forward in the process may be asked to complete an assessment that simulates the responsibilities of this role - CRC (Certified Risk Adjustment Coder from AAPC) is required - One of the following certifications is required in addition to the CRC certification - CPC (Certified Professional Code from AAPC) - COC (Certified Outpatient Coder from AAPC) - CIC (Certified Inpatient Coder from AAPC) - CCS (Certified Coding Specialist from AHIMA) - CCS-P (Certified Coding Specialists Physician Based from AHIMA) What You Will Be Doing Internal Audit Accountabilities - Execute audit procedures as outlined by Leadership including perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by Companies Internal Risk Adjustment Coders/Auditors to ensure consistency and accuracy of ICD-10 coding and industry standards. - Advise Companies Internal Coders/Auditors on proper code selection, documentation guidelines as well as assist with training and education. - Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality review findings and education. External Audit Accountabilities - Perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by External Vendors, Partners and/or Provider Groups to ensure consistency and accuracy of ICD-10 coding. - Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality accuracy reviews/quality audits findings. - Communicate with external Vendors, Partners and/or Provider Groups to share out audit results and educational materials. Senior Audit Accountabilities - Escalates trends in quality accuracy reviews/quality audits findings to Leadership and provide suggested corrective actions - Assists Leadership and resources to support audit scope, deadlines, and objectives. - Assist Leadership with improvements to the quality accuracy reviews/quality audits process, identifying risks, evaluating controls, and preparing documentation. - Assists in developing, maintaining, and updating departmental procedures, workflows, and other work tools/job aides. (30%) What We Require - 4+ years related work experience or equivalent combination of transferable experience in Risk Adjustment Coding, Auditing, Coding Accuracy experience and/or Provider Education - Related Bachelor’s degree or additional related equivalent work experience or equivalent work experience - Demonstrated knowledge of CMS and HHS Risk Adjustment Programs Experience resolving escalated issues and barriers. Excellent communication and collaboration skills both with internal and external audiences Knowledge of health plan operations Knowledge of provider operations - CRC (Certified Risk Adjustment Coder from AAPC) Upon Hire - At least one of the following upon hire: - CPC (Certified Professional Code from AAPC) - COC (Certified Outpatient Coder from AAPC) - CIC (Certified Inpatient Coder from AAPC) - CCS (Certified Coding Specialist from AHIMA) - CCS-P (Certified Coding Specialists Physician Based from AHIMA) What We Prefer - Bachelor’s degree Bachelor’s degree in any subject matter or equivalent work experience - Experience using Full ICD-10 CM code capture - CPMA (Certified Professional Medical Auditor from AAPC) Upon Hire - Demonstrated Florida Blue knowledge - Demonstrated understanding of CMS compliance standards General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. What We Offer As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, short- and long-term disability programs - Leave programs to support personal circumstances - Retirement Savings Plan including employer match - Paid time off, volunteer time off, 10 holidays and 2 well-being days - Additional voluntary benefits available; and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Offer/Hiring Range: $71,200 - $89,000 Annualized Salary Range: $71,200 - $115,700 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. Key position details: - Anticipated Training Class Start Date: 4/27/2026 and 5/25/2026 - Schedule Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. - Day-to-day processing of claims for accounts: - Responsible for processing of claims (medical, dental, vision, and mental health claims) - Claims processing and adjudication. - Claims research where applicable. - Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). - Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. - Investigation and overpayment administration: - Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. - Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. - Utilize systems to track complaints and resolutions. - Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: - 2+ years related work experience. - Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. - High school diploma or GED - Knowledge of CPT and ICD-9 coding required. - Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. - Must possess proven judgment, decision-making skills and the ability to analyze. - Ability to learn quickly and multitask. - Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. - Concise written and verbal communication skills required, including the ability to handle conflict. - Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. - Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: - Some college courses in related fields are a plus. - Other experience in processing all types of medical claims helpful. - Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: - Medical, dental, vision, life and global travel health insurance - Income protection benefits: life insurance, Short- and long-term disability programs - Flexible schedules after training + WAH options! - Leave programs to support personal circumstances. - Retirement Savings Plan includes employer contribution and employer match - Paid time off, volunteer time off, and 11 holidays - Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Job Summary The work of a Sr. Coding & Coding Quality Educator relates to practices and principles associated with medical record auditing and utilizes various techniques in examining, evaluating and providing feedback and training to various stakeholders (certified coders, physician's practices, etc.) Key responsibilities include setting up a standard medical record auditing process and assisting in all matters relating to implementation of coding quality and coding training programs for Coders and Physicians, creating an integrated Program plan to carry out goals and managing/monitoring progress of the program execution. Essential Functions - The essential functions listed represent the major duties of this role, additional duties may be assigned. - Work closely with and coach certified coders and assist in assessing the strengths and weaknesses, ensuring that quality issues translate into timely training and ongoing coding reinforcement to the coders. - Verify, document and communicate quality audit results, develop audit reports and evaluate the effectiveness of corrective action plans and follow up. - Identify coding opportunities and make recommendations to improve internal controls and operational effectiveness and efficiency. - Assist in preparation & development of provider training tools and lead and conduct educational and training programs for physician training on various aspects of documentation and ICD-10-CM coding. - Perform review of specific provider/provider group medical records, develop audit reports and communicate audit results to external physician groups and physician group administration. - Coordinate quality audit program reporting and provider coding training with appropriate areas within Medicare Advantage Risk Adjustment and promote teamwork. - Responsible for the development and ongoing, end-to-end management of the quality audit program ensuring that QA activities and measurements are objective. - Responsible for quality audit program performance and adherence to established ICD-10-CM and CMS-HCC coding guidelines, ensuring compliance with all regulations. - Develop and maintain appropriate reporting, identifying metrics that will reflect true audit program performance. - Gain management concurrence and support for recommended control improvements. - Test and improve training program based upon experience and feedback. - Gather information, constantly update knowledge on various changes that are happening in the field of quality audit and modify coding guidelines to incorporate new knowledge. Share changes with coders as well as physician practices partners. - Manage multiple complex issues and projects simultaneously. - Work collaboratively with other areas of Revenue Program Management to identify, implement and monitor continuous improvement opportunities. - May require travel 0-25% of the time to Florida Blue office locations and provider engagements. Required Experience: 5+ years related work experience. Experience Details: Professional coding including proficiency in ICD-10-CM coding guidelines and risk adjustment HCC coding Related Bachelor’s degree or additional related equivalent work experience AAPC Certified Professional Medical Auditor (CPMA) certification AAPC Certified Professional Coding Instructor (CPC-I) certification 1 Year Knowledge of CMS-HCC risk adjustment data validation process. Organization and time management skills Demonstrate written and verbal communication skills. Preferred Qualifications: Knowledge of government regulations, requirements, and standards related to the management of health information. Knowledge of Scope and Statistical Sampling Methodologies Detail-oriented, commitment to accuracy, ability to problem solve. Working knowledge of MS Office (Excel, Word, PowerPoint) General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Physical/Environmental Activities Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally What We Offer: As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: - Medical, dental, vision, life and global travel health insurance; - Income protection benefits: life insurance, short- and long-term disability programs; - Leave programs to support personal circumstances; - Retirement Savings Plan including employer match; - Paid time off, volunteer time off, 10 holidays and 2 well-being days; - Additional voluntary benefits available; and - A comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Salary Range: $77,600 - $126,100 Typical Annualized Hiring Range: $77,600 - $97,000 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.