Location: Orange, CA
Company: Sedgwick Claims Management Services
Insurance jobs encompass a variety of roles within the insurance industry, ranging from sales and customer service to risk assessment and claims processing. Professionals in this sector typically work for insurance companies, brokerages, or independent agencies, helping individuals and businesses understand and obtain coverage for potential risks. Key features of insurance jobs include analyzing financial risks, providing expert advice on insurance policies, handling policy renewals, and assisting clients with claims. This field requires strong interpersonal skills, attention to detail, and in some positions, analytical abilities to calculate and price insurance premiums. It's a sector known for its stability, opportunities for growth, and contribution to personal and economic security.
has been received. Investigate and complete open or pended claims. Meet production and quality standards. With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island.
Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years,
Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care.
We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS. Minimum Education: High school diploma or equivalent required. Minimum Experience:
Three to five (3-5) years prior medical claims processing experience required.
Knowledge of general claims processing principles, CMS claims coding, and UB-04 claims coding, based on at least three to five (3-5) years experience in claims processing preferably in a managed care environment (IPA, MSO) Req. Certification/Licensure: None. Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system. Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, shop and radiology claims by applying Prospect's policy and procedures and all claim payment criteria.
Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received. Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines. Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations. Achieve stringent productivity goals of 80/10 claims per day/hr.
Initiate recovery of overpaid claims. Also any other duties as requested. Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system. Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, shop and radiology claims by applying Prospect's policy and procedures and all claim payment criteria. Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.
Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines. Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations. Achieve stringent productivity goals of 80/10 claims per day/hr. Initiate recovery of overpaid claims. Also any other duties as requested.
is responsible for being committed to the values of expert clinical practice.
high quality patient care. the advancement of nursing knowledge. and community awareness and education. Additionally assists clinical staff and nurses in their development of high level performance and customer service.
The CNS oversees the orientation program of new hires into the unit, and is responsible for backssing the ongoing learning needs and maintains up-to-date competencies and skills for the nursing staff. This position necessitates involvement in areas of clinical practice, education, consultation, and research. Serves as a positive role model, demonstrating expert professional nursing practice,
strong customer service and enhanced leadership ability. The CNS works on a collegial basis with the other CNS's and Educators at the Medical Center, and is an active participant on various Medical Center committees.
Total Compensation In addition to the salary range listed below, we offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our: Compensation practices ( and Benefits ( Salary Range: Annual Rate Minimum $111,200.00 Midpoint $163,100.00 Maximum $215,000.00 Required
Qualifications: MASTER OF SCIENCE IN NURSING Basic computer literacy and proficiency with MS Word and MS Outlook Working knowledge of Joint Commission and other regulatory requirements present in an acute care setting Current Clinical Nurse Specialist Certification specific to patient population served Strong customer service orientation as well as written and oral communication skills Complete understanding of acuity levels for specific patient populations Minimum of three years of nursing experience in critical care Licenses and Certifications: Advanced Cardiac Life Support(Required) Basic Life Support(Required) Clinical Nurse Specialist(Required) Registered Nurse(Required) Preferred Qualifications: Specialty nursing certification relating to the patient population Conditions of Employment: The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community.
As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment: Background Check and Live Scan Legal Right to Work in the United States Vaccination Policies Smoking and Tobacco Policy Drug Free Environment The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.
California Child Abuse and Neglect Reporting Act E-Verify Pre-Placement Health Evaluation Details of each policy may be reviewed by visiting the following page: Closing Statement: The University of California, Irvine is an Equal Opportunity/Affirmative Action Employer advancing inclusive excellence. All qualified applicants will receive consideration for employment without regard to race, color, religion, interaction, interactionual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC nondiscrimination policy.
We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming. UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at or at (949) 824-xyz X, Monday - Friday from 8:30 a. m. - 5:00 p. m. For more details: jobs-search.
org/insurance_orange-c426406/clinical-nurse-specialist-critical-care-nursing-education-full-time-days-orange_i1955389745
and life insurance401(k) savings plan Awards and recognition programs Responsibilities: Utilize the nursing process to backss, plan, implement, and evaluate patient care. On each assignment, provides skilled nursing care/services in accordance with prescribed orders Assess signs and symptoms indicating physiologic and psychosocial changes in the patient's condition.
Collects, analyzes, and interprets data and information from health care members and documents actual and/or potential nursing diagnoses. Qualifications: Currently licensed as an LPN/LVN in the state in which the LPN/LVN will practice. Current TB or Chest X-Ray. Current BLS card. About Maxim Healthcare Services Maxim Healthcare
Services has been making a difference in the lives of our patients, caregivers, employees and communities for more than 30 years. We offer private duty nursing, skilled nursing, physical rehabilitation, companion care, respite care and behavioral care for individuals with chronic and acute illnesses and disabilities.
Our commitment to quality customer service, compassionate patient care, and filling critical healthcare needs makes us a trusted partner wherever care is needed. Maxim Healthcare Services is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to interaction, gender identity, interactionual orientation,
race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.
For more details: jobs-search. org/insurance_orange-c426406/lvn-private-duty-nurse-full-time-orange_i1949396843
support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive. A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve.
If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you're someone who cares, there's a place for you here. Join us and contribute to Sedgwick being a great place to work. Great Place to Work Most Loved Workplace Forbes Best-in-State Employer Workers Compensation Claims Examiner Orange, CA
Hybrid Shedule Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world's best brands?
Apply your examiner knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world's most respected organizations. Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. Leverage Sedgwick's broad, global network of experts to both learn from and to share your insights. Take advantage of a variety
of professional development opportunities that help you perform your best work and grow your career.
Enjoy flexibility and autonomy in your daily work, your location, and your career path. Access diverse and comprehensive benefits to take care of your mental, physical, financial, and professional needs. OFFICE LOCATION Orange, CAHybrid Schedule ARE YOU AN IDEAL CANDIDATE? To analyze Workers Compensation claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements. PRIMARY PURPOSE OF THE ROLE: We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion.
ESSENTIAL RESPONSIBILITIES MAY INCLUDE Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim. Negotiating settlement of claims within designated authority. Communicating claim activity and processing with the claimant and the client. Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.
QUALIFICATIONS Education & Licensing: 5 years of claims management experience or equivalent combination of education and experience required. High School Diploma or GED required. Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Licensing: SIPJurisdiction: California TAKING CARE OF YOU Flexible work schedule. Referral incentive program. Opportunity to work in an agile environment. Career development and promotional growth opportunities. A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one.
WORK ENVIRONMENT REQUIREMENTS Physical: Computer keyboarding Auditory/visual: Hearing, vision and talking Mental: Clear and conceptual thinking ability; excellent judgement and discretion; ability to meet deadlines. #claiminteractionaminer As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location.
For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($90,000). A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway!
Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles. Requisition #: R44642tcv57hlu2
