- State of Colorado (Colorado Springs, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... CDOC - Liaison III (Step 3 Grievance Responder) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5123844) Apply CDOC -...Board or request a review by the State Personnel Director . An appeal or review must be submitted on… more
- Sanford Health (Sioux Falls, SD)
- …strategic oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, ... adherence to all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end appeals and… more
- CVS Health (Hartford, CT)
- …remote based (work at home) based anywhere in the US. **Responsibilities of this Medical Director role are related to Medicare Appeals :** * Direct daily work on ... AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- Elevance Health (Atlanta, GA)
- **Nurse Appeals ** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing ... between those hours, including holidays on a rotational basis. The **Nurse Appeals ** is responsible for investigating and processing and medical necessity appeals… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory ... appeal. **Work Arrangement:** + Hybrid in Philadelphia **Responsibilities:** + Process appeals , ensuring compliance with all regulatory milestones + Review medical… more
- Humana (Topeka, KS)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- City of New York (New York, NY)
- …planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy ... arise with CFB employees. - Serve as the CFB's grievance representative and administer the contractual grievance ...process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before the Office… more
- Sharp HealthCare (San Diego, CA)
- …and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) ... 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- The Cigna Group (Bloomfield, CT)
- **JOB DESCRIPTION: DENTAL DIRECTOR ** This individual should be passionate about Cigna Healthcare Dental & Vision, clinical dentistry, and contributing to our ... as appropriate. + Act as clinical lead on customer and provider complaints and appeals , as requested. + Manage the development of corrective actions at the member… more
- Guardian Life (Plano, TX)
- The **Dental Director ** will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. You ... will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and...report any quality-of-care issues. In addition, the State Dental Director will be expected to lend support to the… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage review, member… more
- Humana (Indianapolis, IN)
- …not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic ... a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director … more
- Sharp HealthCare (San Diego, CA)
- …physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical Board of CA ... from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains benchmarked utilization… more
- Fallon Health (Worcester, MA)
- …us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance ... standards, other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH… more
- Humana (San Juan, PR)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations… more
- Elevance Health (Costa Mesa, CA)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Associate Medical Director ** **Carelon Medical Benefits Management** **Radiology Benefit Management/Utilization Review** **Virtual** : This… more
- AmeriHealth Caritas (Washington, DC)
- **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the Market President, with oversight of operation services delivered by the ;Healthy DC ... Plan and all relevant federal, state, and local regulatory requirements. The Director Operations Healthy DC Plan is accountable for ensuring the plan's operating… more
- Gwinnett County Public Schools (Suwanee, GA)
- Director of District Title IX Compliance - Division of Human Resources JobID: 99797 + Position Type: Administrative/Managerial/ Dir District Title IX Comp + Date ... to identify and address systemic problems.ESSENTIAL JOB DUTIES1. Lead all Title IX appeals processes for the district. 2. Ensure GCPS policy aligns with government… more
- Molina Healthcare (GA)
- …reduce operational risk in conjunction with Provider Services. * Oversees the Member Appeals and Grievance process; completes analytics to identify trends; and ... executes strategies to improve member satisfaction. * Develops and executes effective member retention strategies to achieve desired retention goals. Also serves as a key partner with community outreach to achieve profitable growth. * Business owner of Member… more
- Transdev (Dorchester, MA)
- …The Labor Relations Manager provides support to the General Manager and Director of Human Resources on labor relations projects, priorities and issues. This ... + Research, compile, and prepare data for use in grievance hearings, arbitration proceedings, labor/management initiatives, collective bargaining negotiations, and… more