- Commonwealth Care Alliance (Boston, MA)
- …including provider listings in their areas. - Complete comprehensive appeal and grievance intakes. - Collaborate with the member to accurately document their appeal ... or grievance concern by ensuring all necessary information to start...preferred - Prior experience with service authorizations, grievances and appeals , scheduling medical appointments preferred - Ability to work… more
- Elevance Health (Woodbridge, NJ)
- **Manager II Grievance / Appeals ** **- Claims Support** **Office Locations:** _The selected candidate must reside within a reasonable commuting distance of the ... an accommodation is granted as required by law._ The **Manager II Grievance & Appeals ** responsible for management oversight of grievances and appeals … more
- Baylor Scott & White Health (Temple, TX)
- **JOB SUMMARY** The Appeals and Grievance Specialist performs reviews, within operational aspects, of the member and provider complaints, appeals and ... of cases; review, research and coordination of complaints, grievances, appeals and reconsiderations consistent with statutory and federal regulatory guidelines.… more
- Motion Recruitment Partners (Birmingham, AL)
- Claims Appeals and Grievance Coordinator Birmingham, Alabama **Onsite** Contract $18/hr - $28/hr Are you detail-oriented, highly organized, and passionate about ... making a difference in healthcare? We are seeking several Appeals and Grievances Coordinators for an onsite contract opportunity in Birmingham, AL. In this role,… more
- AmeriHealth Caritas (Philadelphia, PA)
- …of medical management authorizations.; + Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial ... in a Managed Care environment + 1 to 3 years' experience in grievance / appeals environment required **The Ideal Person will have:** + Proven experience as a… more
- CVS Health (Hartford, CT)
- …AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly ... of this Medical Director role are related to Medicare Appeals :** * Direct daily work on part C ...Appeals :** * Direct daily work on part C appeals (both provider and member/nonparticipating providers). * Provide direct… more
- LA Care Health Plan (Los Angeles, CA)
- …the Clinical Programs. + Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals ... experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment… more
- Elevance Health (Charlotte, NC)
- …by medical directors and consultants; preparing recommendations to uphold or deny appeals ; and ensuring all grievance processes are completed within regulatory ... and/or paralegal experience is strongly desired. + Understanding of the grievance and appeals process is strongly preferred. + Basic knowledge of Medicare and… more
- Molina Healthcare (South Charleston, OH)
- …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... Manages staff responsible for the submission/resolution of member and provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant. +… more
- Molina Healthcare (Columbus, OH)
- …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... tracking system and database of correspondence and outcomes for provider and member appeals ; monitors each appeal to ensure all internal and regulatory timelines are… more
- Molina Healthcare (Spokane, WA)
- Molina Healthcare is hiring for an Appeals & Grievance Specialist. This role is 100% remote and will work in the Pacific Time Zone. This role provides support ... appeals and grievances using support systems to determine appropriate appeals and grievance outcomes. + Requests and reviews medical records, notes, and/or… more
- BayCare Health System (Clearwater, FL)
- …information, documentation, and medical records. + Triage, plan, and execute intake of Appeals and Grievance submissions. + Keeping track of deadlines, ensuring ... management. + Identify trends or recurring issues in member grievances and appeals and recommend process improvements to prevent future occurrences. + Participate in… 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
- Molina Healthcare (MI)
- …claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes. * Requests and reviews medical records, notes, ... **Essential Job Duties** * Facilitates comprehensive research and resolution of appeals , disputes, grievances, and/or complaints from Molina members, providers, and… more
- CVS Health (Carson City, NV)
- …carrying a modified case load including but not limited to:-Research incoming electronic appeals , complaints and grievance to identify if appropriate for unit ... and reroute inappropriate work items that do not meet appeals , complaints and grievance criteria. -Research Standard Plan Design or Certification of Coverage… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …guidelines including URAC, NCQA, and ERISA + Proficiency in Clinical Appeals , Utilization Review, and Grievance processes including benefit interpretation, ... clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit… more
- LA Care Health Plan (Los Angeles, CA)
- …all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters ... inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance /appeal requests, and prepares UM Activity and Weekly Compliance… 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 ... other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH Appeals… 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 ... market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.… more
- CVS Health (Des Moines, IA)
- …and every day. **Position Summary** Plans and executes strategies to meet the Grievance & Appeals organization's long-range goals. Evaluates and develops new ... initiatives and analyzes business opportunities. Develops proposals, including feasibility studies, for new opportunities. Identifies, analyzes and compares alternative opportunities for solutions and adopting new technologies. + Acts as a top-level specialist… more
