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Job Description Hi, we're Oscar. We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family. About the role: The Associate, Risk Adjustment Auditor conducts internal and external quality audits. Quality audits are specific to ICD-10 code abstraction relative to accuracy, completeness, and identified clinical documentation improvement opportunities. You will work with management to implement benchmarks, establish acceptable thresholds, and quality assurance programs. You will report into the Manager, Risk Adjustment. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $82,717 - $108,566 per year You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses. Responsibilities: • Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts., • Mitigate risk by validating Encounter Data Gathering Environment Server (EDGE) data is supported within provider encounter documentation, • Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented., • Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards., • Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits., • Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process., • Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business., • Manage the implementation process improvements that will maximize risk adjustment factor increases., • Compliance with all applicable laws and regulations, • Other duties as assigned Requirements: • Bachelor's degree in a relevant field of study or commensurate work experience., • Certified professional coder (CPC), • 3+ year(s) retrospective risk adjustment coding experience., • 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience Bonus points: • Certified Risk Adjustment Coder (CRC) or similar certification, • Experience coding in a variety of different Electronic Medical Record (EMR) systems. This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

Job Description Position Purpose: The Revenue Cycle Specialist role is to provide support to the organization to address all revenue cycle management needs. This includes identifying trends that would impact revenue, work on patient claims, follow up on denial and rejection related issues, and work on special projects as needed. Position Requirements / Qualifications: Education/Experience: High School Graduate or GED required. At least two (2) years’ work experience in a healthcare front office setting. CPC certification preferred. Knowledge of Medicaid / Medicare insurance, collections, and Explanation of Benefits (EOB). Must have experience in healthcare Billing and Revenue Cycle operational workflow. Licensure / Certification: Maintain current CPR certification from the American Heart Association. Skills / Ability: Ability to work as a team member. Must have clerical skills. Must have knowledge of math, operation of calculator, telephone etiquette, human relation skills and organizational skills. Must be computer literate. Demonstrate effective oral and written communication skills. Familiar with Managed Care Contracts, Medical Terminology, ICD-10, and CPT Codes. Knowledge of collections processes and procedure. POSITION RESPONSIBLITIES (THIS IS A NON-EXEMPT POSITION) • Responsible for identifying, analyzing, and managing Process Improvement projects in the Revenue Cycle area., • Responsible for working the Billing Work Queue impacting revenue for timely review and claims submission (Front/Back Office functions)., • Monitor patient account details for billing related issues., • Reporting claims status to clients on a regular basis to ensure accurate communication between departments within a healthcare organization., • Knowledge of payer guidelines and policies., • Identify and communicate with Director of Patient Access/Office Managers of the front office trends impacting claims rejection/denials for training opportunities., • Provide support to RCM Manager, Coder, Site Office Managers and CBO Vendor in order to expedite claims payments., • Coordinating with other departments to ensure that billing cycles are completed efficiently., • Work the monthly and cumulative missing encounter report by validating open encounters are truly missing and working with the clinicians to ensure that they complete documentation and close encounter., • Access and navigating through various payer portals for claims reconsideration and processing., • Follow up on unpaid claims, appeals of denied claims and post payments/adjustments accordingly., • Review the closed encounters that appear on the missing encounter report to validate a charge filed in Transaction Inquiry., • Supports manager/supervisor in identification of potential loss revenue related to trends in charge entry, billing, coding, or contracting practices that are related to charge capture., • Utilize the coding resources to understand procedures that are denied., • Identify and communicate global payer issues with RCM, Managed Care and Back Office Vendor to generate evidence-based appeals for claims processing reconsiderations., • Understand Managed Care Contracts and various aspects of patient access to maximize claims reimbursement., • Monitor and review monthly Chronic Care Management invoices for Medicare reimbursement., • Responsible for receiving, tracking, and entering hospital encounters into Epic for billing reimbursement., • Export claims data from EHR into RCM Vendor portal for charge posting and billing., • Follow up with all outstanding AR projects as directed by RCM Manager., • Review the Provider Flow fax portal for correspondence communication and distribution., • Complete and submit Quest Diagnostic missing billing details for processing., • Establishes and maintains good interpersonal relationships with clients and staff., • Participates in the RCM monthly meeting with vendor., • Export claims data from EHR into RCM Vendor portal for charge posting and billing., • Follow up with all outstanding AR projects as directed by RCM Manager., • Maintains open communication using appropriate chain of command regarding departmental issues., • Performs other duties as assigned. WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Job Description Job Title: Revenue Cycle Management (RCM) Supervisor Department: Revenue Cycle Management Reports To: Manager of Revenue Cycle Services Position Summary The RCM Supervisor is responsible for overseeing daily revenue cycle operations for a portfolio of independent physician practices served by the company. This role supervises billing, collections, payment posting, denial management, and accounts receivable teams to ensure clients achieve optimal reimbursement, reduced A/R days, and high clean-claim rates. The RCM Supervisor serves as a key liaison between clients, payers, providers, and internal teams, ensuring service excellence and compliance with industry regulations. Essential Duties and Responsibilities Team Leadership • Supervise and support a team of billing specialists, A/R representatives, payment posters, and denial management staff., • Monitor productivity, quality, and performance against established KPIs., • Conduct employee coaching, training, and performance evaluations., • Assist with recruiting, onboarding, and staff development initiatives., • Foster a culture of accountability, customer service, and continuous improvement.Revenue Cycle Operations, • Oversee end-to-end revenue cycle processes for assigned physician practice clients., • Ensure timely claim submission and resolution of claim edits and rejections., • Monitor insurance follow-up activities and collection efforts., • Review and manage aged accounts receivable and work queues., • Ensure accurate payment posting, adjustments, and reconciliation activities., • Oversee denial management and appeals processes to maximize reimbursement., • Escalate payer issues and identify reimbursement trends affecting client revenue.Client Relationship Management, • Serve as the primary operational contact for assigned client accounts., • Participates in regular client meetings to review financial performance and operational metrics., • Present reports on collections, A/R aging, denial trends, and revenue opportunities., • Address client concerns and develop action plans to improve performance., • Collaborate with providers and practice managers to resolve workflow and documentation issues impacting reimbursement.Performance Management & Reporting, • Monitor and analyze key performance indicators, including:, • Days in Accounts Receivable (A/R), • Net Collection Rate, • Gross Collection Rate, • First-Pass Resolution Rate, • Clean Claim Rate, • Denial Rate, • Aging Over 90 and 120 Days, • Charge Lag, • Payment Posting Turnaround Time, • Prepare and distribute operational and financial reports to management and clients., • Identify revenue leakage and recommend corrective actions.Compliance & Quality Assurance, • Ensure compliance with HIPAA, payer regulations, and billing guidelines., • Monitor adherence to Medicare, Medicaid, and commercial payer requirements., • Conduct quality audits of claims, payment posting, and collection activities., • Maintain documentation and process standards required for client contracts and audits.Process Improvement, • Identify workflow inefficiencies and implement best practices., • Collaborate with coding, credentialing, and implementation teams to improve revenue cycle outcomes., • Support system enhancements, software implementations, and automation initiatives., • Develop standard operating procedures (SOPs) and training materials.Qualifications Education • Associate's degree required; Bachelor's degree in Healthcare Administration, Business Administration, Finance, or related field preferred.Experience, • Minimum 5 years of medical billing and revenue cycle management experience., • Minimum 2 years of supervisory or team leadership experience., • Experience managing multi-specialty physician practice accounts preferred., • Experience working for a medical billing company, RCM vendor, or physician management organization strongly preferred.Knowledge & Skills, • Comprehensive knowledge of physician billing and revenue cycle operations., • Strong understanding of CPT, ICD-10, HCPCS, and payer reimbursement methodologies., • Experience with Medicare, Medicaid, commercial insurance, and managed care plans., • Proficiency with practice management systems and EHR platforms., • Advanced Excel and reporting skills., • Strong analytical, organizational, and client-facing communication abilities., • Ability to manage multiple client accounts simultaneously.Preferred Certifications, • Certified Revenue Cycle Representative (CRCR), • Certified Professional Biller (CPB), • Certified Professional Coder (CPC)Key Success Metrics, • Achieve or exceed client collection goals., • Maintain A/R days within target benchmarks., • Improve first-pass claim acceptance rates., • Reduce denial volumes and aged receivables., • Meet client service level agreements (SLAs)., • Maintain high client satisfaction and retention rates., • Achieve team productivity and quality standards.

Job Description SUMMARY: In-person Full Time 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 in patient’s record prior to claim submission, • Codes for assigned physicians, locations, and/or departments from review of medical record documentation., • Applies knowledge of current coding and billing requirements to assure claims are submitted correctly, • Brings identified concerns and trends to the manager/team lead for resolution., • Reviews coding and billing worklists and resolves claim rejections., • Enters patient demographic information and verifies patient insurance coverage QUALIFICATIONS: • Working knowledge of CPT and ICD10 coding, • Medical coding certification (AAPC or AHIMA) preferred or currently in progress, • Minimum 1 year experience in medical billing and coding, • Excellent attention to detail and follow up, • Knowledgeable of payer rules and requirements for both coding and eligibility checking, • High school diploma or general education degree, • Computer skills required: Efficient data entry skills for both speed and accuracy JOB TYPE / WORK SCHEDULE: • This is a full-time In-person position,, • Standard office hours, Monday – Friday, • Bilingual (Required) Competitive pay and a full benefits package, including 401(k), health, dental, vision, life, and disability insurance.

Job DescriptionSUMMARYThis position is intended to provide billing and claims management support to Alivi Specialty Networks and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner will ensure all claims received comply with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines and processes.DUTIES & RESPONSIBILITIES • Responsible for accurate and timely adjudication of professional and institutional claims according to state and federal regulations., • Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately., • Demonstrate skills in problem solving, benefit plan, and provider contract Interpretation., • Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 Codes, under the correct provider contract and member benefits., • Responds to provider disputes in a timely and accurate manner., • Research provider disputes to ensure appropriate claims dispute resolutions., • Works Directly with Clinical Review Board and Network Operations Team to resolve complex issues or disputes., • Adjudicates claims that have been overturned by the Clinical Review Board or Network Operations Team., • Generates written correspondence to members, providers, and regulatory agencies., • Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines., • Determines and processes overpayments (provider refunds) and reimbursement requests according to specific state and/or federal guidelines or as agreed to in provider contract., • Determines and processes underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence., • Maintains the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing., • Identifies trends in claims flows and suggests process improvements., • Assist in preparation with Claims Audits., • This position description identifies the responsibilities and tasks typically associated with the performance of the position.REQUIREMENTS, • High School diploma or equivalent., • 3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare., • Hands-on working experience processing medical claims in insurance industry., • Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees)., • Self-starter, ability to work independently and in a team environment., • Strategic, analytical, process oriented and must have critical thinking skills., • Excellent written and verbal communication skills., • Ability to manage multiple priorities., • Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities., • Works well under pressure., • Proficient with Excel, PowerPoint, Word & Outlook., • Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes., • Knowledge of Correct Coding (CCI) Edits., • Experience in gathering all necessary documentation in preparation of Delegation Audits., • Detailed knowledge of electronic billing processes universal billing forms., • Knowledge of CMS/ACHA Regulations is desirable., • Previous Experience using Health Suite is desirable. Certified Professional Coder (CPC) is desirable. Powered by JazzHR 6B8Srn28MU

Job DescriptionBenefits: • 401(k) matching, • Competitive salary, • Dental insurance, • Health insurance, • Paid time off About Us We are a fast-growing, innovative medical billing company committed to transforming the healthcare revenue cycle through technology, transparency, and top-tier customer service. Our team is passionate about simplifying the complexities of medical billing so healthcare providers can focus on what matters mostpatient care. We're seeking a highly motivated and experienced Charge Posting (Coder) Supervisor to join our leadership team and help us continue delivering exceptional results to our clients across the country. Job Overview As the Medical Coder Supervisor, you will lead group of certified coders to accurately review and approval encounters using industry coding guidelines, optimize workflow efficiency, and oversee a high-performing medical coding team. You'll be responsible for the training, on-going development, quality assurance audits, and covering for coder when necessary to maintain overall high level performance of the assigned team. Key Responsibilities • Oversee and manage the data entry and coding guidelines for commercial, Medicaid, and Medicare to ensure first pass claim submissions., • Develop and implement coding policies, procedures, and performance metrics to ensure efficient and accurate billing processes., • Lead, mentor, and evaluate the performance of the Charge Posting team., • Monitor KPIs including DSO, denial rates, and collection percentages, and proactively address areas of concern., • Collaborate with internal departments and external clients to troubleshoot complex billing issues., • Stay current on healthcare regulations, payer policies, and industry best practices., • Drive continuous improvement through data analysis, automation opportunities, and workflow redesign. Qualifications • Certified Coder with 3+ years of progressive experience in medical billing and revenue cycle management., • Proven leadership experience in a dynamic, high-volume billing environment., • Strong knowledge of commercial and government payer guidelines, CPT/ICD-10 coding, and compliance requirements., • Excellent analytical, communication, and problem-solving skills., • Experience with medical billing software (e.g., AdvanceMD, Kareo, eClinicalWorks, Greenway-Intergy, Athenahealth, or similar platforms)., • Ability to thrive in a fast-paced, client-focused environment. Why Join Us? • Competitive salary, • Opportunities for growth and professional development, • Supportive and collaborative company culture, • Impactful work that makes a real difference for healthcare providers and patients Ready to lead the charge in revenue optimization and operational excellence? Apply today and help us redefine the future of medical billing.

Job DescriptionBenefits: • Health insurance, • 401(k), • Paid time off, • 401(k) matching, • Competitive salary, • Dental insurance, • Flexible schedule, • Vision insurance Benefits/Perks • Flexible Scheduling, • Competitive Compensation, • Careers AdvancementJob Summary We are seeking a Medical Coder to join our team. In this role, you will transcribe patient records and process claims for reimbursements. You will be responsible for selecting the correct codes and functions to be assigned to each instance. The ideal candidate is detail-oriented with strong people skills and computer skills. Experience using Mod-Med system preferred. Responsibilities • Account for coding and abstracting of patient medical appointments, • Research and analyze data needs for reimbursement, • Ensure codes are properly sequenced, • Analyze, file, and process medical records, • Keep detailed documentation of any deficiencies or issues with medical records, • Provide education and training to other coding staff, • Review and verify documentationQualifications, • High school diploma/GED or equivalent, • Previous experience as a Medical Coder or in a similar position, • Familiar with coding software and other computer programs, • Strong written and verbal communication skills, • Highly organized and able to problem-solve, • Ability to adhere to strict confidentiality guidelines Flexible work from home options available.

We are seeking a detail-oriented and experienced Medical Billing Specialist with a strong background in medical billing, coding, and insurance processes. The ideal candidate will be skilled in medical terminology, procedure coding, cost estimation, insurance appeals, and working within electronic health record systems. This role requires accuracy, excellent communication skills, and the ability to work with both patients and payers to ensure timely and correct reimbursement. This position may offer the opportunity to work from home, depending on experience and performance. Key Responsibilities: Accurately process and submit medical claims to insurance companies, government payers, and other third-party organizations. • Perform medical coding using ICD-10, CPT, and HCPCS standards for a variety of procedures and diagnoses., • Generate and communicate cost estimates for procedures based on insurance coverage and contract agreements., • Review and verify accuracy of billing data within EHR/EMR systems prior to claim submission., • Utilize EHR/EMR platforms (such as Epic, Meditech, PrognoCis) for documentation, coding, and billing workflows., • Research and resolve billing discrepancies or claim denials., • Prepare and submit insurance appeals, ensuring compliance with payer guidelines., • Communicate with patients regarding billing questions, payment responsibilities, and insurance coverage., • Maintain up-to-date knowledge of medical terminology, payer requirements, and compliance regulations (HIPAA, CMS, etc.)., • Collaborate with clinical staff and providers to ensure accurate coding and documentation within electronic systems., • Track accounts receivable and follow up on outstanding claims to maximize revenue. Requirements Qualifications: • High school diploma or equivalent required; Associate’s degree in Healthcare Administration, Billing & Coding, or related field preferred., • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification strongly preferred., • Minimum of 2 years of experience in medical billing, coding, insurance follow-up, and working within EHR/EMR systems., • Strong knowledge of ICD-10, CPT, and HCPCS coding systems., • Hands-on experience with electronic health record (EHR) and electronic medical record (EMR) systems, including Epic, Meditech, and/or PrognoCis., • Familiarity with medical terminology, payer reimbursement guidelines, and healthcare regulations., • Experience creating cost estimates for medical procedures., • Skilled in preparing and submitting appeals for denied claims., • Proficiency with medical billing software and electronic health record (EHR) systems., • Strong attention to detail, problem-solving, and organizational skills., • Excellent written and verbal communication skills. Preferred Skills: • Experience with Medicare/Medicaid billing and commercial insurance., • Advanced knowledge of EHR/EMR workflows and system navigation., • Ability to work independently and manage multiple tasks in a fast-paced environment., • Customer service experience in a healthcare setting.

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better? The Coding Specialist II reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. The PB Coding Specialist II performs Current Procedural Terminology (CPT) and International Classification of Diseases, volume 10 (ICD10) coding through abstraction of the medical record with a focus on more complex encounters and/or has expertise with HCPCs procedural codes. This position has deep understanding of disease process, A&P and pharmacology and acts as a key collaborator with Providers and Clinical areas to ensure the medical record accurately reflects the patient's service. This position trains physicians and other staff regarding documentation, billing and coding, and performs various administrative and clerical duties to support the roles core function. The Coding Specialist II also demonstrates expertise to resolve Optum coding edits. Responsibilities: • Utilizes technical coding expertise to reviews the medical record thoroughly, utilizing all available documentation abstract and code physician professional services and diagnosis codes (including anesthesia encounters, operative room and surgical procedural services, invasive procedures and/or drug infusion encounters). Additionally, may include coding for Evaluation and Management services, bedside procedures and diagnostic tests as needed., • Follows Official Guidelines and rules in order to assign appropriate CPT, ICD10 codes and modifiers with a minimum of 95% accuracy., • Ensures charges are captured by performing various reconciliations (procedure schedules, OR logs and clinical system reports), • Provides documentation feedback to physicians, • Maintains coding reference information, • Trains physicians and other staff regarding documentation, billing and coding., • Reviews and communicates new or revised billing and coding guidelines and information, • Attends meetings and educational roundtables, communicates pertinent information to physicians and staff., • Resolves pre-accounts receivable edits. Identifies repetitive documentation problems as well as system issues., • Makes appropriate changes to incorrectly billed services, adds missing unbilled services, provides missing data as appropriate, corrects CPT and ICD9 codes and modifiers. Adds MBO tracking codes as needed., • Collaborate with Patient Accounting, PB Billing, and other operational areas to provide coding reimbursement expertise; helps identify and resolve incorrect claim issues and is responsible for drafting letters in order to coordinate appeals, • Acts as key point person for Revenue Cycle staff and Account Inquiry Unit staff in obtaining documentation (notes, operative reports, drug treatment plans, etc.). Provides additional code and modifier information to assist with appealing denials. May contact providers for peer-to-peer reviews., • Meets established minimum coding productivity and quality standards for each encounter type, • May perform other duties as assigned. Required: • Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC) certification or Certified Coding Specialist (CCS)., • Zero (0) to two (2) years of experience in a relevant role., • 94% accuracy on organizations coding test. Preferred: • Bachelor's or Associate's degree in a Health Information Management program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)., • Previous experience with physician coding. Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our _ section to learn more.

Date Posted: June 18, 2025 The _ seeks a part-time contract SAS Programmer to support the Research and Cost Trends (RCT) department in updating and maintaining the data infrastructure used to prepare the All-Payer Claims Database (APCD), advise on structural changes to case-mix and evaluate existing tools used in analytic file creation. This is an opportunity for a detail-oriented, skilled SAS coder with previous experience working with health insurance enrollment files, medical claims, and pharmacy claims, as well as datasets maintained by the Massachusetts Center for Health Information and Analysis (CHIA). The SAS Programmer will join the Research and Cost Trends (RCT) department and will report directly to the Manager of Research and Cost Trends. Duties of the position may include, but are not limited to: Updating programs to allow for changes in new releases of the All-Payer Claims Database (APCD); Advising and creating best practices to integrate CHIA’s Master Patient Index (MPI) that is updated on a quarterly basis and allows linking across APCD and case-mix; Integrating the 3M Core Grouping Software into the analytic pipeline; Integrating the HHS-HCC risk adjustment model into the analytic pipeline; Validating HPC’s methods for processing MassHealth ACO/MCO/FFS claims; Helping integrate MassHealth MCO processing into commercial processing such that both sets of claims can be processed simultaneously; Identify and eliminate outdated SAS code in programs to help reduce confusion for future processors; Advising HPC on processing Medicare Advantage claims and make changes to existing programs as needed to allow for Medicare Advantage analytic file creation; and Providing ongoing on-demand support for technical issues The HPC operates a hybrid work schedule, with employees splitting their time between the downtown Boston office and remote work. Desired Qualifications: Advanced Degree in Computer Science, Information Systems Management, or related field; At least 5 years of experience with SAS programming, data infrastructure maintenance, and analytic file creation; Previous experience working with claims data such as Center for Health Information Analysis All-Payer Claims Database preferred; Excellent oral, written, and interpersonal skills and the ability to work in groups; The ability to balance multiple and competing priorities in a fast-paced work environment; A commitment to fostering an inclusive workplace that promotes collaboration amongst diverse viewpoints, facilitates cooperation and teamwork, and supports constructive resolution of conflicts; A strong interest in public service and desire to advance a more transparent, accountable, and equitable health care system for all Massachusetts residents. Candidates must be eligible to work in the United States. Compensation and Benefits Compensation Range $140-$155 per hour worked, up to 20 hours of work a week. An initial maximum contract obligation of 120 hours. Compensation is commensurate with experience. The HPC may adjust title, responsibilities, and compensation depending on the experience and expertise of the individual selected. This is a contract position for up to one year of work. This position is not eligible for benefits other than limited sick leave. Our Commitment: The HPC is committed to a policy of non-discrimination and equal employment opportunity. We recognize that diversity in the workplace is a source of strength, vital to its ability to effectively advance its mission. The HPC is committed to: Actively promoting diversity in our workforce, including greater racial and ethnic diversity, at all levels of the organization; Fostering a work environment in which all employees are inspired to do their best, strengthened by their different perspectives, backgrounds, and experiences; Ensuring that no employee’s growth, achievement, or advancement is hindered because of race, ethnicity, sex, sexual orientation, religion, age, genetic information, gender identity, pregnancy, veteran status, or disability; Holding ourselves to a high standard of inclusion and opportunity that will serve as a model for other public and private employers throughout the Commonwealth; Promoting our core values of equal opportunity, equal justice, and inclusion in HPC actions and initiatives.

\n JOB DESCRIPTION\n\n\n Provides investigative support for special investigation unit (SIU) activities specific to medical provider coding fraud, waste and abuse (FWA). Investigates and resolves instances of health care fraud and abuse investigations of medical providers using informational tips from member benefits and medical records following review of post-payment claims. \n\n\n Essential Job Duties\n\n\n • Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, all relevant and applicable Federal and State regulatory requirements, and Molina policies.\n, • Reviews post-pay claims against corresponding medical records to determine accuracy of claims payments. \n, • Manages documents and prioritizes caseloads to ensure timely turnaround. \n, • Ensures adherence to applicable state/federal/internal policies, Current Procedural Terminology (CPT) guidelines and provider contract requirements.\n, • Devises clinical summary post-review.\n, • Communicates and participates in meetings related to cases.\n, • Completes medical review to facilitate referral to law enforcement or payment recovery. \n, • Supports investigation work as necessary and required by the regulatory agency.\n\n\n Job Requirements\n\n\n, • At least 2 years CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience.\n, • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified\n, • Critical-thinking, problem-solving and analytical skills. \n, • Ability to prioritize and manage multiple tasks.\n, • Ability to work in a team setting.\n, • Strong verbal/written communication skills, and presentation skills.\n, • Microsoft Office suite (including Excel), and applicable software program(s) proficiency.\n, • In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements). \n, • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.\n, • Knowledge of Managed Care and the Medicaid, Medicare, and Marketplace programs.\n, • Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.\n, • Ability to research and interpret regulatory requirements.\n\n\n Preferred Qualifications\n\n\n, • Certified Professional Compliance Officer (CPCO). \n, • Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI). \n, • Experience working in group health insurance, particularly within claims processing or operations. \n, • Working knowledge of local, state and federal laws and regulations pertaining to health insurance, investigations and legal processes (commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.). \n, • Experience with claims processing systems. \n, • Ability to use Microsoft Excel/Access platforms working with large quantities of data. \n, • Ability to answer questions, identify trends and patterns, and present findings. \n\n\n #PJCorp\n\n\n #LI-AC1\n\n\n To all current Molina employees. If you are interested in applying for this position, please apply through the Internal Job Board. \n \n \n Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V\n Pay Range: $21.82 - $42.55 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Under the direction of the Business Office Director, the Medical Insurance Biller II is responsible for the timely and accuracy submission of hospital medical claims. Proficiency in medical terminology, coding systems and medical billing procedures. Certified Medical Coder preferred.

Physician-Care-Centers-1 is looking for a Remote Medical Coder to ensure accurate and compliant coding for provider encounters. The ideal candidate will have 2–3 years of medical coding experience and strong attention to detail while adapting to evolving guidelines.

Miami Jewish Health is seeking an HCC Risk Adjuster and Coder to review medical records and accurately code and sequence diagnoses to maximize reimbursement. The role requires a minimum of 1 year of HCC/ ICD-10-CM coding experience, an associate degree in health information management, and strong kn