UNKNOWN

FEED

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.). 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).

Molina Healthcare Inc

Investigator, Special Investigative Unit Coding (Remote)

FULL_TIME

Under the direction of the Vice President of Compliance, and in close partnership with the Special Investigations Unit (SIU) Manager, the SIU Medical Record Audit Manager provides leadership and strategic direction for IEHP’s prepayment and post-payment medical record audit functions within the Fraud, Waste, and Abuse (FWA) framework. Prepayment Review Performance Lead end to end prepayment medical record review operations, including documented criteria for placing and releasing providers, turnaround compliance within claims payment timeframes, yield optimization, false positive monitoring, inventory aging, and scheduled reassessment and exit decisions.

YEAR

Inland Empire Health Plan

Manager, Special Investigations Unit Medical Record Audit

[AW]-iCims

Our clients are enterprises as diverse as sophisticated financial institutions and start-ups, global public firms, and middle-market companies, as well as high net worth individuals, family offices, not-for-profit organizations, and entrepreneurial ventures across a variety of industries. In this role, you will partner closely with FAS leadership and engagement teams to identify and address professional, regulatory, and operational risks early, while developing practical controls, workflows, and training that support engagements from intake through case closure.

EisnerAmper

Risk Management Senior Manager, Financial Advisory Services

ea_via_bold

Risk Management Manager, Financial Advisory Services

This role is an extension of our Special Investigations Unit (SIU) that sits within Legal-you will spend your days investigating suspected fraud against Clover''s Medicare Advantage business and ensuring that those investigations are coordinated, well-documented, and supported by the right legal advice from the Legal department. Collaborate Across Functions: Work with Clover''s clinical, compliance, claims, payment integrity, provider relations, revenue operations, and SIU teams to gather information, validate findings, and translate investigative outcomes into operational improvements, provider education, and member impact.

Clover Health Investments Corp

Director, Fraud Investigations

TAG EisnerAmper, LLC (Inactive)

Leads or directs the preparation of cases for presentation to outside agencies, leads or directs pursuit of criminal or civil actions through gathering and documenting relevant data, organizing and summarizing facts and testifying on behalf of the company in civil or criminal matters. Performs a combination of duties in accordance with departmental guidelines: Leads the detailed analysis and completion of thorough and timely investigations of suspected claim fraud by following Best Practice Guidelines and collaborating with insureds, claimants, witnesses and experts.

CNA's approach to research is a modern iteration of the Newtonian principle that complex, dynamic processes are best understood through direct observation of events and people.

That was the methodology CNA analysts first applied in the 1940s when they pioneered the field of operations research by helping the Navy address the German U-boat threat. Not content to study the problem from afar, this small group of MIT scientists insisted on deploying with Navy forces in order to observe operations and collect the data needed for meaningful analyses. Their groundbreaking work, and the anti-submarine warfare equations it produced, set a standard for operations research methods that CNA has maintained for 75 years.

Today, with more than 500 professionals at our headquarters and 50 researchers in the field, CNA still takes a multi-disciplinary, real-world approach to our work. On-site analysts carefully observe all aspects of a process—people, decisions, actions, consequences—and then collaborate with a headquarters-based research team to assess data and arrive at findings.

CNA's objective, empirical research and analysis helps decision makers develop sound policies, make better-informed decisions, and manage programs more effectively. Our work, which in its early decades focused solely on defense-related matters, has grown to include investigation and analysis of a broad range of national security, defense, and public interest issues including education, homeland security and air traffic management. Through our Center for Naval Analyses and Institute for Public Research, we provide public-sector organizations with the tools they need to tackle the complex challenges of making government more efficient and keeping our country safe and strong.

SIU Senior Consultant

LPC, LMHC, LPCC, LCPC, LCMHC, LCMHCS, LCPCS, LPMHC, LIMHP, LMHP, LPC-MH, LPC-MHSP, MSLPC and other eligible independent clinical counseling licenses. We're looking for independently licensed mental health therapists, counselors, clinical social workers, marriage and family therapists, and psychologists who can provide therapy without supervision.

BetterHelp is the largest online counseling platform worldwide. We change the way people get help with facing life's challenges by providing convenient, discreet and affordable access to a licensed therapist. BetterHelp makes professional counseling available anytime, anywhere, through a computer, tablet or smartphone.

BetterHelp

Online Mental Health Counselor

In addition to Peach Tree Healthcare's company values, this role will be assessed on the following competencies: Clinical Excellence: Demonstrates advanced medical judgment, diagnostic expertise, and the application of evidence-based practices to analyze complex medical cases, workplace exposures, and regulatory requirements while making sound clinical decisions. This position provides medical oversight of occupational health programs, fitness-for-duty evaluations, regulatory compliance, workers' compensation case management, medical surveillance programs, and workplace health initiatives.

Peach Tree Health Inc

Occupational Medicine Physician

Online Mental Health Social Worker

Licensed Counselor / Therapist – Remote

OTHER

The ideal candidate is highly organized, accurate, and comfortable managing multiple financial priorities independently in a fast-paced, compliance-focused environment. Review corporate and clinical invoices, determine the appropriate processing method, and code expenses to the correct programs and accounts.

Cala Sourcing Solutions LLC

Staff Accountant

WorkWolf

Veteran's Credit: Pursuant to the County Charter and County policy, in all open competitive examinations (i.e., examinations open to everyone), the County of Los Angeles will add a credit of 10 percent of the total credits specified for such examination to the final passing score of an honorably discharged veteran, as well as the spouse of a deceased or disabled veteran, who served in the Armed Forces of the United States under specific conditions. Please add the following ealcazar@hr.lacounty.gov; info@governmentjobs.com; talentcentral@shl.com; noreply@proctoru.com; donot-reply@amcatmail.com to your email address and list of approved senders to prevent email notifications from being filtered as spam/junk/clutter email.

Los Angeles County

FORENSIC PATHOLOGIST (PHYSICIAN SPECIALIST)

CNA Financial Corp

Strong command of U.S. patent drafting and prosecution requirements, including patent eligibility, novelty, obviousness, written description, enablement, and claim clarity; familiarity with PCT procedures and foreign prosecution through local counsel. We’re intentional, we’re unapologetically curious and we’re 100% committed to innovate space-based communications and deliver actionable intelligence that will expand global economies, protect space and our planet and enhance our overall quality of life.

E-Space

Senior Patent Agent

Analyze and calculate ability to pay settlements and judgments, including analyzing debt covenants, borrowing capacity, adjusted earnings and earnings per share, financial ratios, accounts receivable and accounts payable, aging schedules, tax considerations, assessing collectability, and developing payment terms and schedules. CGS is seeking a Senior Auditor who will assist the district legal staff by conducting medical claims data analysis, forensic investigations, financial damages, statistical sampling, and ability-to-pay analyses, which serve a significant role in determinations regarding investigations, prosecutions, settlements, and recovery in these matters, which can be voluminous and complex.

CONTACT GOVERNMENT SERVICES

Senior Auditor

Incumbents perform progressively responsible and diverse law enforcement duties such as supervising, observing, guarding, and transporting inmates; serving civil and criminal process; securing and maintaining order within courtrooms; patrolling an assigned area in a patrol car; investigating, preventing and suppressing crime; and apprehending public offenders. Incumbents are assigned to fixed posts or designated patrol areas throughout the unincorporated area of the County and in contract cities and perform either: (1) inmate custody work at a correctional facility; security and support services at a court facility; or (2) law enforcement work at a Sheriff's patrol station, specialized unit, or other non-custodial assignment.

AAlusion

Deputy Sheriff-Lateral

Assess risk of liquidation of assets in the context of an Asset Based Loan, primarily through detailed testing of transactions and development of borrowing base calculations to ensure lenders are properly secured against deteriorating performance of a borrower. Our plans are cost-effective, convenient and provide progressive ways for staying healthy, protecting loved ones, pursuing financial security and living a full and balanced life.

IMA Financial Group

Director, Lender Due Diligence

GreenHouseAPI

Ability to: layout and review the work of other staff; prepare designs and make accurate drawings and maps; make accurate mathematical calculations and neat and accurate field notes; perform site evaluations; understand, interpret, and explain various California building and residential code requirements; apply principles of logic and scientific reasoning to develop and evaluate alternative courses of action and determine appropriate solutions; read, understand, and interpret complex technical and legal documents, maps, technical drawings, and plans; listen attentively and participate in negotiations by providing required data and information; adjust workload changes and work under stress to meet deadlines; develop and maintain effective working relationships with all levels of representatives from governmental and private agencies, construction and consultant contractors, coworkers, and the public; write clearly and concisely in order to prepare technical reports, correspondence, and maintain records. Civil: Considerable knowledge of: the principles, practices, and techniques of civil engineering; statistics and advance mathematics including algebra and analytic geometry; topographic and construction surveying, stress analysis, analytical mechanics and the strength, properties and uses of construction materials; building codes; construction materials; common methods and equipment utilized in engineering construction and of inspection methods used in reviewing such work; real property descriptions; civil engineering design and drafting methods and equipment and computer-aided design (CAD) software.

HOUR

County of Sonoma

Engineer

Deep working knowledge of §101 subject matter eligibility and a record of getting software claims allowed — you can articulate why a claim recites a technical improvement rather than an abstract idea, and you draft specifications that support that argument from the start. Draft and prosecute U.S. and international applications covering machine learning architectures, training and inference systems, and software platforms, with claim and specification strategy built to withstand subject-matter eligibility challenges under §101.

Claims Examiner Jobs in California

Investigator, Special Investigative Unit Coding (Remote) Molina Healthcare Inc

Manager, Special Investigations Unit Medical Record Audit Inland Empire Health Plan

Risk Management Senior Manager, Financial Advisory Services EisnerAmper

Risk Management Manager, Financial Advisory Services EisnerAmper

Director, Fraud Investigations Clover Health Investments Corp

Risk Management Manager, Financial Advisory Services TAG EisnerAmper, LLC (Inactive)

SIU Senior Consultant CNA

Online Mental Health Counselor BetterHelp

Occupational Medicine Physician Peach Tree Health Inc

Online Mental Health Social Worker BetterHelp

Licensed Counselor / Therapist – Remote BetterHelp

Staff Accountant Cala Sourcing Solutions LLC

FORENSIC PATHOLOGIST (PHYSICIAN SPECIALIST) Los Angeles County

SIU Senior Consultant CNA Financial Corp

Senior Patent Agent E-Space

Senior Auditor CONTACT GOVERNMENT SERVICES

Deputy Sheriff-Lateral AAlusion

Director, Lender Due Diligence IMA Financial Group

Engineer County of Sonoma

Patent Agent, Software Hark

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