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Creating remarkable health experiences, freeing people to be their best.
Appeals Analyst
Location
United States
Posted
106 days ago
Salary
$22 - $33 / hour
No structured requirement data.
Job Description
Appeals Analyst
Highmark Health
Company : Highmark Inc.Job Description : JOB SUMMARY This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results. ESSENTIAL RESPONSIBILITIES - Review inquiries to determine if they meet definition of appeal/grievance. - Request and review all related relevant documentation and assemble case file. - Coordinate resolution results and relay investigative results with all involved parties. - Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends. - May support the Quality Assurance, Appeal and other quality committees. - Other duties as assigned or requested. EDUCATION Required - High School Diploma or GED Substitutions - None Preferred - None EXPERIENCE Required - 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016. Preferred - Experience in Customer Service or a related field LICENSES or CERTIFICATIONS Required - None Preferred - None SKILLS - Knowledge of multiple processing systems and workflows - Knowledge of claims processing methodologies - Ability to interpret all government regulations - Knowledge of company products - Excellent organizational skills - Strong verbal and written communication skills Languages (Other than English) None Travel Requirement 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Occasionally Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Occasionally Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $21.53 Pay Range Maximum: $32.95 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice
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Medical Information Specialist I-Nurse- Fully remote!
Thermo Fisher ScientificThe World Leader In Serving Science
Work Schedule Standard (Mon-Fri) Environmental Conditions Office Job Description At Thermo Fisher Scientific team, you’ll discover impactful work, innovative thinking and a culture dedicated to working the right way, for the right reasons - with the customer always top of mind. The work we do matters, like helping customers find cures for cancer, protecting the environment, and supporting our customers’ medical related inquiries. As the world leader in serving science, with the largest investment in R&D in the industry, our colleagues are empowered to realize their full potential as part of a fast-growing, global organization that values passion and unique contributions. Our commitment to our colleagues across the globe is to provide the resources and opportunities they need to make a difference in our world while building a fulfilling career with us. What will you do in this role? As a Medical Information Specialist I - Nurse, you will provide technical and medical information, and/or perform intake of adverse events/product complaints with quality customer service. You will analyze and research inquiries and document interactions according to organizational, client, and regulatory guidelines. The information you provide will be given to a level in parallel with your expertise, experience, and training. Responds accurately and professionally to technical and medical information inquiries received via phone, email, internet or mail in reference to pharmaceutical or device products. Processes fulfillments and provides clinical trial information or after-hours on call support. Analyzes caller’s questions to formulate an accurate and concise response using client-approved resources and records inquiries and interactions in the appropriate databases following organizational, client and regulatory guidelines. Identifies, records and triages adverse events and product complaints according to organizational, client and regulatory guidelines and provides additional support (including follow up) as needed. Maintains thorough knowledge of project and corporate policies and procedures including client products, SOPs, protocols, GCPs, and applicable regulatory requirements. Works closely with internal and external client contacts (up to and including members of client management) to resolve complex inquiries. As needed, researches medical literature and drafts responses for such inquiries. Qualification requirements: Education requirements Bachelor's degree in Nursing and equivalent and relevant formal academic / vocational qualification In some cases, an equivalency, consisting of a combination of appropriate education, training and/or directly related experience, will be considered sufficient for an individual to meet the requirements of the role. Experience requirements Previous experience that provides the knowledge, skills, and abilities to perform the job (comparable to 0 to 2 years) is required. Active RN license required or Nurse Licensure Compact (NLC) equivalency is required. Must be willing to work the hours needed outlined below for this client's needs: • Rotating shifts required, primarily supporting evening hours of 11am-7pm or Noon-8pm EST • Support rotating after-hours on-call assistance on a rotating basis, ensuring 24/7 coverage Knowledge, Skills and Abilities: Excellent verbal and written communication skills Excellent language skills (comprehension, speaking, reading and writing); Fluency skills in a second language may be required Proficient computer and keyboarding skills Good interpersonal skills Ability to work independently as well as part of a team. Ability to interpret client provided complex medical and technical information Organizational and time management skills Ability to maintain a positive and professional demeanor in challenging circumstances Location: Fully remote role. Relocation is not provided. *Must be legally authorized to work in the United States without sponsorship. *Must be able to pass a comprehensive background check, which includes a drug screening. Our Mission is to enable our customers to make the world healthier, cleaner and safer. Watch as our colleagues explain 5 reasons to work with us. As one team of 100,000+ colleagues, we share a common set of values - Integrity, Intensity, Innovation and Involvement - working together to accelerate research, solve complex scientific challenges, drive technological innovation and support patients in need. #StartYourStory at Thermo Fisher Scientific, where diverse experiences, backgrounds and perspectives are valued. Apply today! http://jobs.thermofisher.com Thermo Fisher Scientific is an EEO/Affirmative Action Employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability or any other legally protected status. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation. Accessibility/Disability Access Job Seekers with a Disability: Thermo Fisher Scientific offers accessibility service for job seekers requiring accommodations in the job application process. For example, this may include individuals requiring assistance because of hearing, vision, mobility, or cognitive impairments. If you are a job seeker with a disability, or assisting a person with a disability, and require accessibility assistance or an accommodation to apply for one of our jobs, please submit a request by telephone at 1-855-471-2255*. Please include your contact information and specific details about your required accommodation to support you during the job application process. *This telephone line is reserved solely for job seekers with disabilities requiring accessibility assistance or an accommodation in the job application process. Messages left for other purposes, such as not being able to get into the career website, following up on an application, or other non-disability related technical issues will not receive a response.
Selection Technician
START Center for Cancer ResearchSTART clinical trial sites have conducted more than 1,000 early-phase clinical trials, including dozens of therapies that were approved by the FDA or EMA. START represents the world’s largest roster of early-phase principal investigators across its Network of clinical trial sites. Committed to accelerating passage from trials to treatments, START delivers hope to patients, families, and physicians around the world via our mission of “Hope Through Access.” As an example, in San Antonio, where START was founded, START treated the first patient ever with Keytruda – one of the most effective cancer drugs in medical history. Learn more at STARTresearch.com.
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Vacante disponible: Técnico de Selección (Temporal con posibilidad a indefinido) - Colaborar con los directores para atraer y reclutar talento de alto nivel, construyendo relaciones sólidas que permitan comprender las necesidades de selección. - Impulsar proactivamente los procesos de selección para cubrir las vacantes en el menor tiempo posible. - Adoptar un enfoque estratégico en la construcción y mantenimiento de un sólido pipeline de talento, utilizando networking y redes sociales para conectar con candidatos altamente calificados. - Garantizar una experiencia excepcional para el candidato desde el primer contacto hasta la negociación de la oferta, mediante una comunicación clara, efectiva y orientada al servicio. - Desarrollar estrategias de atracción efectivas para reducir la dependencia de agencias externas, aprovechando información del mercado para optimizar los procesos de búsqueda. - Monitorear continuamente tendencias y mejores prácticas del sector, adaptando los enfoques para fortalecer la atracción y selección de talento. - Medir y analizar indicadores clave de selección, proporcionando a los directores información y reportes periódicos que faciliten la toma de decisiones y optimicen el proceso de contratación. - Asegurar que todas las actividades de selección cumplan con las leyes, regulaciones aplicables y los estándares organizacionales. - Colaborar con el equipo de Talent Acquisition para implementar procesos estandarizados y compartir mejores prácticas. - Gestionar relaciones con socios externos y proveedores que apoyen los objetivos de Talent Acquisition. Qualifications - Licenciatura en Administración de Empresas, Recursos Humanos, Psicología o carrera afín. - Experiencia en selección de ciclo completo en entornos dinámicos y de ritmo acelerado. - Experiencia en adquisición de talento dentro de la industria farmacéutica, CRO, biotecnología y/o sector salud. - Inglés avanzado (indispensable). - Se valorará positivamente el conocimiento de otro idioma. Benefits - Jornada de Lunes a Viernes (Festivos y Fines de Semana libres). - 30 días laborables de vacaciones. - Retribución flexible. - Posibilidad de realizar clases particulares de inglés totalmente gratuitas.
Sr. Actuarial Technician
Fidelity & Guaranty Life Insurance CompanySince 1959, Fidelity & Guaranty Life Insurance Company (F&G) has offered annuity and life insurance products to those who are seeking security in retirement and protection during life’s unexpected events. F&G believes in an employee-centric flexible environment, which is why we offer the ability for in-office, hybrid and remote work arrangements. F&G complies with federal and state disability laws and makes reasonable accommodations for applicants and candidates with disabilities, unless such accommodation would cause an undue hardship for F&G. Join our employee-centric hybrid work environment. F&G is a proud equal opportunity employer.
Job Summary The Sr. Actuarial Technician is a key member of the Actuarial Modeling team that delivers on some of its responsibilities, including model development and the execution of corresponding controls and other governance activities around that process. Duties and Responsibilities - Proficient in the use of tools used by the Actuarial Modeling team, including the Moody’s AXIS modeling platform and the specific implementation of F&G models within this platform; Excel and Alteryx are other common tools used by this team. - Proficient in understanding the operational mechanics of F&G products and applicable reinsurance, and their implications to their modeling - Proficient in basic actuarial concepts demonstrated by effectively supporting actuaries within the team in their job functions, in conjunction with being able to contribute to and enhance existing model documentation - Develops and maintains these tools and models - Assists in governance and controls activities related to model change management, including updating or otherwise enhancing model documentation - Validates and analyzes model results - Collaborates within the respective team, as well as with key upstream and downstream stakeholders Experience and Education Requirements - Bachelor’s Degree preferred, ideally in Actuarial Science, IT, Math / Statistics or other related technical field - 2-4 years of experience in financial services industry - Experience supporting an organization’s actuarial function preferred Knowledge, Skills & Abilities - Strong problem solving and analytical skills, including the ability to quickly and effectively learn new concepts and technical tools, including the Moody’s actuarial modeling platform AXIS and Sharepoint - Ability to adapt rapidly and thrive in a quickly evolving and dynamic work environment - Project management skills, including staying on top of and managing expectations for multiple projects of varying priorities and timelines - Takes ownership for responsibilities, with attention to detail demonstrated through high quality of work product - Team player prioritizing meeting group objectives, demonstrated by seeking opportunities to support other important team activities - Self-starter who demonstrates strong initiative, including a continuous desire to enhance tools and processes through challenging the status quo - Effective verbal and written communication skills - Proficient in Microsoft Office applications, such as Word, Excel, and PowerPoint; Access preferred Other Requirements - Perform other functions, duties and projects as assigned - Regular and punctual attendance - Some travel required (less than 10%) #LI-JB1 #LI-Remote Additional Information Work Environments F&G believes in an employee-centric flexible environment, which is why we offer the ability for in-office, hybrid and remote work arrangements. During the hiring process, you'll work with your leader to decide what works best for your role. F&G complies with federal and state disability laws and makes reasonable accommodations for applicants and candidates with disabilities, unless such accommodation would cause an undue hardship for F&G. If reasonable accommodation is needed to participate in the job application or interview process, please contact talentacquisition@fglife.com. Join our employee-centric hybrid work environment: F&G Careers About F&G Since 1959, Fidelity & Guaranty Life Insurance Company (F&G) has offered annuity and life insurance products to those who are seeking security in retirement and protection during life’s unexpected events. As a national Top Workplace1, an Iowa Top Workplace2 and a proud equal opportunity employer, F&G team members are empowered, collaborative, dynamic and authentic. We believe that by embracing these values, we will continue to build and strengthen the company while continuing to be a great place to work. 1Top Workplaces USA 2022 – 2023 2Des Moines Register Top Workplaces 2018 – 2022 Notice for all Applicants who are California residents under the California Privacy Rights Act. Please click here to review the policy.
Certified CMMC Professional
Insight AssuranceInsight Assurance is a cybersecurity compliance and risk management firm dedicated to simplifying the complexities of compliance for organizations worldwide through a comprehens
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We are seeking a knowledgeable and motivated Certified CMMC Professional (CCP) to support the delivery of CMMC readiness and advisory services for clients in the Defense Industrial Base (DIB). The CCP will work directly with organizations seeking to meet CMMC 2.0 and NIST SP 800-171 compliance requirements. This role serves as a trusted advisor, assisting clients with documentation, gap assessments, remediation planning, and readiness activities in preparation for formal CMMC assessments conducted by Certified Third-Party Assessment Organizations (C3PAOs). - Conduct CMMC readiness assessments and gap analyses against CMMC 2.0 practices and NIST SP 800-171 requirements. - Assist in developing and reviewing key compliance documents such as System Security Plans (SSPs) and Plans of Action and Milestones (POA&Ms). - Support clients in implementing cybersecurity controls and processes aligned with CMMC 2.0 Levels 1 and 2. - Collaborate with IT, security, and compliance teams to identify risks and track remediation efforts. - Provide expert guidance and interpretation of CMMC requirements, helping organizations understand their obligations under DFARS 252.204-7012/7019/7020. - Prepare clients for official CMMC assessments by reviewing evidence, policies, and technical configurations. - Stay current with updates from The Cyber AB, DoD, and NIST related to the CMMC 2.0 program. - Communicate findings and recommendations clearly through reports, presentations, and client meetings. - Work closely with Certified CMMC Assessors (CCAs) or C3PAO partners to align client readiness efforts with official assessment standards. Qualifications - Active Certified CMMC Professional (CCP) credential issued by The Cyber AB. - U.S. Citizenship (required for DoD and DIB-related engagements). - 3–5+ years of experience in cybersecurity, compliance, risk management, or audit. - Strong understanding of CMMC 2.0, NIST SP 800-171, and related DoD cybersecurity regulations. - Experience performing gap analyses, security documentation reviews, and compliance consulting. - Excellent communication and analytical skills with the ability to explain technical concepts to non-technical audiences. - Ability to work independently and manage multiple client engagements in a fast-paced environment. Preferred Qualifications - Bachelor’s degree in Cybersecurity, Computer Science, Information Systems, or a related field (or equivalent experience). - Additional certifications such as Security+, CISSP, CISA, or CAP. - Experience supporting defense contractors or working in environments handling Controlled Unclassified Information (CUI). - Familiarity with Microsoft GCC High, AWS GovCloud, or other compliant cloud environments. - Prior experience working with or for a Certified Third-Party Assessment Organization (C3PAO). Benefits - Flexible Paid Time Off and paid Holidays - Quarterly Performance Bonuses - 100% Remote - Competitive salary and benefits package. - Opportunities for professional growth and development. - Collaborative and innovative work environment.

