Insurance OpportunitiesFirstHealth of the Carolinas, Inc
FirstCarolinaCare Insurance Company (FCC) is a small regional health insurance company that is owned by a not-for-profit regional hospital system, FirstHealth of the Carolinas. It is located in Pinehurst, NC. FCC provides group health insurance plans for employers based in North Carolina as well as Medicare Advantage plans for Medicare eligible individuals.
We are currently hiring for the following:
Operations Analyst – Medicare Advantage:
Performs random audits of claims processed weekly to ensure quality of work and to identify root causes of errors so corrective action can be taken to fix the error.
Bachelor's Degree in Business, Management, or a related area. Significant experience may be accepted in lieu of formal education. Five years experience in claims processing, benefit building, healthcare billing, managed care contracting, and/or patient accounting. Two years experience in customer service and/or provider service. One year experience in auditing and/or training. Experience with Medicare Advantage is preferred.
Office automation/personal computer skills with excellent knowledge level in Excel, Word, and Microsoft Access. Requires strong verbal and written communication skills, conflict resolution and negotiation skills, and ability to provide strong attention to detail. Advanced knowledge of CPT coding, ICD-9 coding, and medical terminology.
Coordinates the care and services for members who have intensive needs secondary to the occurrence of a critical event or diagnosis or for those who have multiple or complex conditions that requires the intense use of resources.
Current, active fully-licensed North Carolina Registered Nurse or Compact State Nursing license with a Baccalaureate degree in Nursing preferred. Minimum of 5 years of recent clinical experience required. Experience with Home Care, Discharge Planning or Care Management experience a plus. Case Management Certification required within on year of employment.
Utilization Management Coordinator:
The Utilization Management Coordinator is a Registered Nurse responsible for ensuring requests for specific health care services are medically necessary.
Current, active fully-licensed North Carolina Registered Nurse or Compact State nursing license, with a Baccalaureate degree in nursing required. Knowledgeable on application of Medical Necessity principles, procedures and criteria. Minimum of 3-5 years of recent clinical experience, preferably involved with care management, discharge planning, or home health care. Experience in reviewing health care services for medical necessity in a clinical setting or in a utilization management role or similar activities required. Knowledge of the managed care industry, health benefits industry, and N.C. insurance laws needed. Familiarity with requirements of accrediting bodies such as NCQA or URAC preferred. Detail-oriented and excellent communicator. Excellent documentation skills and time management a must. Must work well with physicians and all other health care providers. Must be comfortable using various clinical and Microsoft applications. NC Drivers license and reliable transportation necessary.