Jobs in Pinellas Park Pinellas County Fl Flexible

Medical Claims Manager for TPA Organization

Pay: $95K-$110K Base Salary PLUS Annual Incentive Bonus based on performance

Position Summary:

Third-Party Administrator (TPA) Company which provides a wide range of administrative services to insurance companies, sharing organizations, insurance marketing organizations, and employers. One core service is claims administration, where submissions for payment/reimbursement/sharing from medical providers and covered individuals are reviewed, subject to cost controls and ultimately adjudicated, resulting in an explanation of handling to the submitter.

This service is provided subject to service level agreements which mandate a high level of service measured by timely turnaround and a high degree of accuracy. Accuracy is measured by adherence to all written procedures and controls applicable to claims as well as the client’s stated coverage.

Qualifications and Competencies -Education and/or Experience:

• A minimum of at least 5-7 years in a Management role for Claims Operations, servicing health insurance policies or benefits.
• Third Party Administrator “TPA” experience required.
• In-depth knowledge of computerized automated claims adjudication is required.
• Experience in network vendor relations, experience in network repricing, and reference base pricing concept for our of network claims would a plus.
• Excellent written and verbal communication skills. A college degree is preferred.

Certificates, Licenses, Registrations:

• Project Management certification (e.g., PMP) or industry-related certifications (e.g., CEBS) a plus but not required

Supervisory Responsibilities:

• Leadership & Team Development

Competencies:

• Leadership & Team Development
• Operational Efficiency & Workflow Optimization
• Conflict Resolution & Change Management
• Strategic Planning & Growth Support
• Excellent Communication (Written & Verbal)
• Detail-Oriented, Organized, and Tech-Savvy

Computer Skills:

• Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook, Electronic Health Records.
• Familiarity with benefit administration platforms, CRM tools, project management software, and database systems preferred.

Essential Duties and Responsibilities:

• Participation in product development, including the technical review of new products and prospective new clients. This assistance will be focused on evaluation and interpretation of benefits, advancements in health care requiring updates to programs and plans, and advancements in administration, including use of AI.
• Ensuring that daily reporting provides an accurate portrayal of claims on hand, including those received by the clearinghouse, sent to re-pricing entities, unable to be systematically “matched”, auto-adjudicated, in Examiner queues waiting to be adjudicated, and in either audit or needing approval status.
• Developing and implementing strategies for greater automation in the claims process, including electronic receipt of claims and auto-adjudication.
• Establishing production requirements for Examiners, and along with the Supervisor monitoring performance against the requirements.
• Establishing and monitoring strong operational controls relating to claims cost control, including review processes for potential pre-existing conditions, determining medical necessity, enforcing reasonable charge provisions and pursuing recovery of third-party liability.
• Monitoring and continually developing Policies and Procedures intended to enforce consistency in process and improve quality.
• Working with the Manager of Quality to implement appropriate standards for accuracy and audit procedures intended to validate those standards are met. This includes setting release authority levels and random audit percentages for Examiners reflecting experience and historical quality results. It will also include development of coaching and training programs linked to emerging quality issues.
• Using audit results to develop ongoing training programs and new procedures intended to increase procedural, payment and financial accuracy percentages.
• Coordinating escalations from other Departments with the Claims Supervisor to ensure that timely and complete actions and responses are provided.
• Reviewing and approving higher dollar claims prior to payment.
• Oversight for the ongoing management of claims processing technology, including plan building and identification of new and updated benefit categories based on new medical coding and medical services.
• Act as a liaison with clients for escalation of service issues or program questions, establishing a strong working relationship and client trust.
• Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS.
• Participates in Product Development and Sales processes, including participation when requested in prospective client presentations, regulatory reviews and contracting of vendors.

Essential Duties Specific to Claims Department:

• Participating actively as a key member of the Management Team, including demonstrating leadership through strong communications skills, use of business metrics to determine strategy and resource needs, and showing a high level of focus on continual quality improvement.
• Coordination of all activities of the Claims Department Management Team. This includes Supervisors and/or Team Leaders assigned to Customers.
• Responsibility for Claims Department strategy, planning, staffing projection, budgeting and quality assurance and improvement.
• Responsibility for Interviewing and final recommendation for hiring employees within the Claims Department. This is to ensure that high standards are maintained, and compensation arrangements are discussed and approved by the executive team.
• Creating a culture within the Claims Department of exceptional service to members and their providers, as well as transparency in reporting results, trends and issues to Senior Management and clients.
• Management of relationships with Preferred Provider Organizations and Reference-Based Pricing vendors which are essential to managing the cost of claims for clients.
• Management of relationships with essential vendors involved with the Claims Adjudication process, including clearinghouses, claims cost control vendors and the claims fulfillment vendor (printing and mailing of checks and EOP/EOB, as well as electronic payments).
• Identification and management of Subject Matter Experts (SMEs), with back-ups in various aspects of Claims, including procedures and use of technology.
• Oversight of Claims Training programs, including training for new employees and ongoing reinforcement training.
• Oversight of Claims documentation, including Policies and Procedures and reference materials.
• Participates in RFP/Proposal processes, including participation when requested in prospective client presentations.

Primary Performance Expectations:

Performance review for the Claims Manager is ongoing, with formalized reviews quarterly. There will be an Annual Review completed each January which will determine adjustments to compensation, and availability of incentive compensation. Performance expectations or goals are as follows:

Budget Performance:

The Claims Manager will be evaluated based on the level of variance with the budget established for the Claims Department, measured by staffing and other expenses. Operating expenses for the Claims Department will be measured by total per household per month (PHPM) and per inbound claim cost so that improvements in productivity and efficiency are rewarded.

Department Results for Service Level Agreements:

SLA results will be measured quarterly and reported specifically by client.

Department Satisfaction Level:

An annual Satisfaction Survey will be provided to the relationship manager for each PAS client where Claims services are provided. The Departments will be graded in total and by Team, and in each case must be graded with a score of at least 4 out of 5 (Highly Satisfied).

Department Quality Level:

The Department will be audited by Enterprise Risk Management (ERM). Actual results will be compared to goals in each period.

HIPAA and Data Privacy Obligations:

This role has direct access to Protected Health Information (PHI). The following rules are non-negotiable:

• Absolute confidentiality: Employees must not disclose PHI to unauthorized individuals under any circumstances.
• Secure environment: A private, locked workspace must be maintained to prevent exposure of PHI to family members, visitors, or others.
• Company-approved technology only: All work must be performed on secure, company-issued devices using encrypted connections (VPN required).

You will be required to complete HIPAA training upon hire and annually thereafter. Any breach of confidentiality or unauthorized disclosure of patient information may result in disciplinary action up to and including termination and may carry legal consequences under state or federal law.

Other Responsibilities:

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee. Duties, responsibilities, and activities may change at any time with or without notice.

• Adheres to the policies and procedures of Company.
• Maintains strict confidentiality of client, company, and personnel information.
• Demonstrates a strong commitment to the mission and values of the organization.
• Adheres to company attendance standards.
• Performs other duties as assigned.

#GEN

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Paid training
• Vision insurance

Company Description

SkyBeach Resort is a luxury resort in the heart of St. Petersburg, Florida, offering a unique blend of relaxation and cutting-edge customer experiences. With our private beach, marina, and state-of-the-art amenities, we are dedicated to redefining hospitality. Our team is committed to creating exceptional guest experiences in an inviting and innovative environment. Join us in delivering unparalleled service at one of Florida’s most scenic destinations.

Role Description

This is a full-time on-site position in St. Petersburg, FL, for a Kitchen Receiver & Prep Cook. The role involves receiving and inspecting kitchen deliveries, ensuring inventory accuracy, and maintaining proper food storage standards. The candidate will assist with food preparation, follow hygiene protocols, and support the kitchen team in daily operations while maintaining a clean and organized workspace. Cooperation with the team to ensure high-quality meal preparation and seamless kitchen operations is essential.

This position reports to the Executive Chef of the Resort.

Compensation: up to $19 per hour

Qualifications

• Strong skills in Food Preparation and basic Cooking techniques
• Knowledge of Hygiene standards and food safety regulations
• Effective Communication skills and ability to work in a collaborative team environment
• Customer Service mindset with a focus on providing quality and timely results
• Ability to work in a fast-paced hospitality environment
• Prior experience in food handling or culinary roles is preferred
• High school diploma or equivalent is required
• Flexibility to work varied shifts, including weekends and holidays

Stroke response times nearly half of the national average. Cutting-edge SPOT Technology that detects sepsis earlier than the human eye. An Enhanced Surgical Recovery program that reduces opioid prescriptions and post-surgical readmissions. As a national learning health system, we're transforming care delivery, advancing clinical outcomes, and empowering our nursing teams in a collaborative effort to give people a healthier tomorrow. Join us! 

We are seeking a Progressive Clinical Nurse Coordinator Registered Nurse. You will provide clinical expertise to ensure all patients receive high quality, efficient care in a high acuity environment in a leadership role. We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. Take the next step in your nursing career.

What you will do in this role:

• You will assess, plan, intervene and evaluate the care of PCU patients.
• You will instruct patients and families regarding medications and treatment instructions
• You will maintain and review patients’ records including posting tests and examination results
• You will administer medications in accordance with physician orders
• You will provide leadership to your nursing team during your designated shift

Requirements:

• Must be licensed as a Florida Registered Nurse in accordance with state regulations or appropriate compact licensure. If compact license held, active FL RN license required within 60 days of hire.
• Nursing Diploma or ASN required; BSN Preferred
• Current BLS (Basic Life Support) required 
• Minimum 1 year RN experience in acute care setting preferred
• Critical thinking, service excellent and good interpersonal communication skills, ability to read/comprehend written instructions, ability to follow verbal instructions, PC skills

No Travel Required 

1 years experience Required 

HCA Florida South Tampa Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services 
• Wellbeing support, including free counseling and referral services 
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence 
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling 
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing 
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts 

Learn more about Employee Benefits 

Note: Eligibility for benefits may vary by location. 

For over 40 years, HCA Florida South Tampa Hospital has been providing comprehensive healthcare services. We provide high-quality medical care. We also provide surgery, outpatient therapies, and acute care. With a team of skilled colleagues, it's no wonder we have a reputation for excellence. The over 180-bed acute care hospital is accredited by the Joint Commission. We provide 24-hour Emergency Care, Behavioral Healthcare, and Cardiovascular Services. We also provide General Surgery and Imaging & Diagnostic Services. As South Tampa Hospital and ER, we provide high quality, advanced care. We are one of the best-performing hospitals in the Tampa Bay area. We believe excellent people make excellence happen. If this sounds like the type of meaningful work you'd like to be a part of, we hope you'll consider our careers at South Tampa Hospital.

HCA Healthcare has been named one of the World's Most Ethical Companies by Ethisphere Institute for ten consecutive years (2 In 2019, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder 

Join a family that cares about every stage in your career! We are interviewing candidates for our RN Registered Nurse PCU Charge opening. Apply today and a member of our Talent Acquisition team will reach out. 

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Stroke response times nearly half of the national average. Cutting-edge SPOT Technology that detects sepsis earlier than the human eye. An Enhanced Surgical Recovery program that reduces opioid prescriptions and post-surgical readmissions. As a national learning health system, we're transforming care delivery, advancing clinical outcomes, and empowering our nursing teams in a collaborative effort to give people a healthier tomorrow. Join us! 

We are seeking a Registered Nurse to join our Pre-Op / Phase II Recovery / Same Day Surgical Services Department. You will provide clinical expertise to ensure all patients receive high quality, efficient care in a surgical environment. We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply now.

What you will do in this role:

• You will assess, plan, intervene and evaluate the care of Pre-Op and Phase II Recovery patients.
• You will instruct patients and families regarding medications and treatment instructions.
• You will maintain and review patients’ records including posting tests and examination results.
• You will administer medications in accordance with physician orders.

What qualifications you will need:

• Licensure as a Florida Registered Nurse in accordance with state regulations or appropriate compact licensure. If compact license held, active FL RN license required within 60 days of hire.
• Nursing Diploma or ASN required; BSN preferred.
• Previous experience in an acute care setting strongly preferred.
• Current BLS (Basic Life Support) certification required.
• Current ACLS (Advanced Cardiac Life Support) 
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, ability to follow verbal instructions, PC skills

HCA Florida West Tampa Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services 
• Wellbeing support, including free counseling and referral services 
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence 
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling 
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing 
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts 

Learn more about Employee Benefits 

Note: Eligibility for benefits may vary by location. 

For over 40 years, HCA Florida South Tampa Hospital has been providing comprehensive healthcare services. We provide high-quality medical care. We also provide surgery, outpatient therapies, and acute care. With a team of skilled colleagues, it’s no wonder we have a reputation for excellence. The over 180-bed acute care hospital is accredited by the Joint Commission. We provide 24-hour Emergency Care, Behavioral Healthcare, and Cardiovascular Services. We also provide General Surgery and Imaging & Diagnostic Services. As South Tampa Hospital and ER, we provide high quality, advanced care. We are one of the best-performing hospitals in the Tampa Bay area. We believe excellent people make excellence happen. If this sounds like the type of meaningful work you’d like to be a part of, we hope you’ll consider our careers at South Tampa Hospital.

HCA Healthcare has been named one of the World’s Most Ethical Companies by Ethisphere Institute for ten consecutive years (2 In 2019, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder 

Join a family that cares about every stage in your career! We are interviewing candidates for our RN Registered Nurse Endocrine Surgery Pre Post opening. Apply today and a member of our Talent Acquisition team will reach out. 

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Stroke response times nearly half of the national average. Cutting-edge SPOT Technology that detects sepsis earlier than the human eye. An Enhanced Surgical Recovery program that reduces opioid prescriptions and post-surgical readmissions. As a national learning health system, we're transforming care delivery, advancing clinical outcomes, and empowering our nursing teams in a collaborative effort to give people a healthier tomorrow. Join us! 

We are seeking a Charge Critical Care Registered Nurse for our ICU. You will provide clinical expertise to ensure all patients receive high quality, efficient care in a high acuity environment in a leadership role. We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. Take the next step in your nursing career.

What you will do in this role:

• You will assess, plan, intervene and evaluate the care of critically ill patients.
• You will instruct patients and families regarding medications and treatment instructions
• You will maintain and review patients’ records including posting tests and examination results
• You will administer medications in accordance with physician orders
• You will provide leadership to your nursing team during your designated shift

Requirements:

• Must be licensed as a Florida Registered Nurse in accordance with state regulations or appropriate compact licensure. If compact license held, active FL RN license required within 60 days of hire.
• Nursing Diploma or ASN required; BSN Preferred
• Current BLS required 
• ACLS required within 6 months of hire of transfer
• Minimum 1 year RN experience in acute care setting preferred
• Critical thinking, service excellent and good interpersonal communication skills, ability to read/comprehend written instructions, ability to follow verbal instructions, PC skills

HCA Florida South Tampa Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services 
• Wellbeing support, including free counseling and referral services 
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence 
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling 
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing 
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts 

Learn more about Employee Benefits 

Note: Eligibility for benefits may vary by location. 

For over 40 years, HCA Florida South Tampa Hospital has been providing comprehensive healthcare services. We provide high-quality medical care. We also provide surgery, outpatient therapies, and acute care. With a team of skilled colleagues, it's no wonder we have a reputation for excellence. The over 180-bed acute care hospital is accredited by the Joint Commission. We provide 24-hour Emergency Care, Behavioral Healthcare, and Cardiovascular Services. We also provide General Surgery and Imaging & Diagnostic Services. As South Tampa Hospital and ER, we provide high quality, advanced care. We are one of the best-performing hospitals in the Tampa Bay area. We believe excellent people make excellence happen. If this sounds like the type of meaningful work you'd like to be a part of, we hope you'll consider our careers at South Tampa Hospital.

HCA Healthcare has been named one of the World's Most Ethical Companies by Ethisphere Institute for ten consecutive years (2 In 2019, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder 

Join a family that cares about every stage in your career! We are interviewing candidates for our RN Registered Nurse ICU Charge opening. Apply today and a member of our Talent Acquisition team will reach out. 

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Wooster, OH, offers physicians the opportunity to practice in a thriving, community-oriented environment with strong healthcare support from institutions like Wooster Community Hospital and the Cleveland Clinic-affiliated facilities.

Doctors can build meaningful relationships and provide high-quality, personalized care.

The city's affordable cost of living, excellent school systems, and vibrant local culture make it an ideal place for families.

Additionally, Wooster's proximity to Cleveland provides access to advanced medical resources and professional development, while allowing physicians to enjoy the charm and work-life balance of a smaller town.

Your CompHealth recruiter will be your advocate assisting you with contract negotiation, including pay, benefits, and incentives with insights into facilities and national market trends.

Contact Zachary Richman .

Hybrid model; 1 week remote and 1 week onsite 12 weeks of PTO Monday through Friday from 8 am
- 5 pm Employed and independent contractor opportunities No call High earning potential; base plus RVUs Negotiable sign-on bonus No noncompete Our services are free for you We help negotiate your salary and contract We coordinate interviews and help with licenses Specialized recruiters match your career preferences Experienced support teams take care of every detail From $650000.00 to $650000.00 annual Ranges shown should be used as an estimate and are affected by many factors including the critical need of the position, your overall experience and qualifications, and other considerations.

Please reach out to your consultant for more information.

Northeast Philly suburb practice is seeking a physician for a mix of nursing home and clinic patients.

There is hospital rounding every fourth weekend for the group's patients as well.

Excellent base salary and production incentive available along with benefits.

Located in Bucks County, PA this practice offers easy access to Philadelphia and a friendly staff to work with.

Up to $300,000 base salary.  Flexible scheduling
- As long as the patients are being seen, the doctor can come in as early or as late as desired   Up to 4 weeks PTO.  The average number of patient encounters is 20-25.  Bonuses for additional patients seen will range from $20,000
- $50,000 annually.  Full benefits included.  The community offers terrific schools and easy access to all the amenities of Philadelphia   

Northeast Philly suburb practice is seeking a physician for a mix of nursing home and clinic patients.

There is hospital rounding every fourth weekend for the group's patients as well.

Excellent base salary and production incentive available along with benefits.

Located in Bucks County, PA this practice offers easy access to Philadelphia and a friendly staff to work with.

Up to $300,000 base salary.

Flexible scheduling
- As long as the patients are being seen, the doctor can come in as early or as late as desired Up to 4 weeks PTO.

The average number of patient encounters is 20-25.

Bonuses for additional patients seen will range from $20,000
- $50,000 annually.

Full benefits included.

The community offers terrific schools and easy access to all the amenities of Philadelphia

SMART is seeking Part time Locum Radiologists1.REMOTE Radiologist for day shift June 15 and 16th 2024 2.Breast Radiologist Onsite July 15- 19th No call Qualifications: BC/BE /Active NC LisenceFAST CREDENTIALINGNO CALL NO WEEKENDSSMART provides malpractice coverage, travel, and accommodations for all locum assignments.Please contact Debbie Mollenhauer at or call to learn more about the competitive hourly rates that we are offering for this assignment, or to hear about other openings that we may have available.

SMART is actively recruiting for REMOTE DAY SHIFT Tele Radiologists to provide Locum coverage for a client of ours in Louisiana Coverage is needed with completion of credentialing on an ongoing basisQualifications:Active LA LicenseBoard CertifiedJob Summary:Shift times: M-F 8a-4:30p CSTModalities: CR, RF, US, CT, MR Additional desired subspecialty
- Body, MSK or Neuro75 RVU's per shiftRPCE Tech Stack , Powerscribe 4.0Benefits of Working with SMART:Competitive hourly ratesSMART covers malpractice insurancePaid travel and accommodationsPlease contact Debbie Mollenhauer at Office: or email to learn more about this opportunity, or to hear about other openings that we may have available.Know someone who would be a good fit for this position? SMART offers up to $2500 for referrals so please share job details with your colleagues and send them our way!