- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager , Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances ... net required to achieve that purpose. Job Summary The Manager , Appeals & Grievances (A&G)...cross-functional departments to appropriately address and resolve member and provider grievances . + Responsible for timely daily… more
- Molina Healthcare (South Charleston, OH)
- …**KNOWLEDGE/SKILLS/ABILITIES** + Manages staff responsible for the submission/resolution of member and provider inquiries, appeals and grievances for the ... requirements. + Maintains call tracking system of correspondence and outcomes for provider and member appeals / grievances ; oversees monitoring of each… more
- CareFirst (Baltimore, MD)
- …mandates. Directs the activities and serves as a resource for associates within the Appeals and Grievances Department for Government Programs. We are looking for ... training presentations for internal and external stakeholders. Supports the Manager of Clinical Appeals and Analysis in...data related to the volume and complexity of the appeals and grievances submitted for resolution. **SUPERVISORY… more
- Elevance Health (Atlanta, GA)
- …will make an impact:** + Conducts investigations and reviews of member and provider medical necessity appeals . + Reviews prospective, inpatient, or retrospective ... Director for final review and decision. + Ensures that appeals and grievances are resolved timely to...or any combination of education and experience, which would provide an equivalent background. + Current active unrestricted RN… more
- Elevance Health (Charlotte, NC)
- …providers, and regulatory entities, and serves as a subject matter expert for appeals , grievances , and quality of care issues. + Key responsibilities: serves ... **Nurse Appeals - Litigation & Legal Support** **Location:** North...or any combination of education and experience, which would provide an equivalent background. + Current active unrestricted RN… more
- Molina Healthcare (AZ)
- …+ Deep understanding of claims lifecycle, EDI transactions, payment integrity, provider data, appeals / grievances , and audit/compliance (CMS, HIPAA, ... management with direct impact on Claims Operations (adjudication, configuration, appeals / grievances , payment integrity, provider data). **Preferred… more
- Fallon Health (Worcester, MA)
- … and grievances addressed to the Member Appeals & Grievances Department. This position will also provide administrative support to the department. ... of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and… more
- Insight Global (Mayfield Heights, OH)
- …Authorization/Gold Carding, Eligibility/Benefits Verification, Claim Submission, Adjudication, Payment, Appeals / Grievances ) * Clear and confident communicator, ... standards and procedures, and prioritize them for assigned areas * Provide guidance, recommendations, and mentor other business analysts on approach, guidance,… more
- LA Care Health Plan (Los Angeles, CA)
- …Functional knowledge of Membership Eligibility and Enrollment, Member Maintenance, PCP assignment, Appeals and Grievances preferred. EDI 5 years of EDI Domain ... Technical Applications Manager II Job Category: Information Technology Department: IT...public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.… more
- Transdev (Dorchester, MA)
- …and governmental laws and regulations. + Manage the grievance process and provide comprehensive responses to complaints, grievances , and arbitrations that ... Transdev in Boston, MA is seeking a Labor Relations Manager for its Boston Public Schools transportation contract. The...policies and procedures and regulations for accurate resolution of appeals , complaints, and grievances . + Understand legal… more
- State of Colorado (Limon, CO)
- …plans, and conducts performance evaluations; resolves informal staff and/or inmate grievances . Assigns tasks, monitors and inspects work progress and ensures ... inmate hours and pay, creates schedule and assigns tasks and resolves informal grievances according to agency policy; reduces inmate idleness and creates real life… more
- CHS (Clearwater, FL)
- …client trust. * Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS. Participates ... **Overview** **Claims Manager ** **Servicing** **Health Insurance Policies or Benefits** **Summary:** Premier Administrative Solutions (PAS) is a Third-Party… more
- Elevance Health (IN)
- …Law Enforcement). + Assists and participates in appeal or fair hearings, member grievances , appeals , and state audits. **Minimum Requirements:** + BA/BS degree ... **LTSS Service Coordinator (Case Manager )** **Location:** Seeking candidates to work in Greene,...clinical healthcare management and interdisciplinary team in order to provide care coordination support. + Manages non-clinical needs of… more
- Elevance Health (Norfolk, VA)
- …unless an accommodation is granted as required by law. The **Vendor Implementation Manager ** is responsible for Provider Network 3rd party delegated dental, ... **Vendor Implementation Manager ** **Hybrid 1:** This role requires associates to...Transportation) strongly preferred + Experience with Medicaid and Medicare grievances and appeals processes + Experience with… more
- AmeriHealth Caritas (Washington, DC)
- …internal metrics and regulatory requirements, including call center SLAs, member and provider grievance & appeals , claims timeliness, provider credentialing, ... **Job Responsibilities** The Performance Sustainability Manager (Healthy DC Plan) will report directly to...Coordinates problem resolution efforts with the Medical Affairs and Provider Services departments regarding complaints and grievances … more
- LA Care Health Plan (Los Angeles, CA)
- …technical aspects of the retrospective review process for authorizations and Member or Provider Appeals , including, but not limited to computer data entry, ... public agency created by the state of California to provide health coverage to low-income Los Angeles County residents....nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and … more
- Elevance Health (Chillicothe, OH)
- …Law Enforcement). + Assists and participates in appeal or fair hearings, member grievances , appeals , and state audits. **Minimum Requirements:** + Requires BA/BS ... **LTSS Service Coordinator (Case Manager )** **Hiring near Cambridge, Colerain, Chillicothe, Coschocton, Hillsboro, Ironton, Mansfield, Marion, Mount Orab, Mount… more
- Sharecare (Albany, NY)
- …open enrollment / new hire plan selection, claims issues, ID card issues, grievances / appeals , utilization management (UM) status, including but not limited to ... an exciting and innovative remote role newly created to provide meaningful support to members and their families through...payers or 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …must maintain licensure throughout employment + Minimum of 5 years' experience in Clinical Appeals and Grievances within a managed care or payor setting + ... quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager . Note: This job description is not intended to be an… more
- Sharp HealthCare (San Diego, CA)
- …+ Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify trends in ... care needs of the membership. Serves as a medical manager and policy advisor to SHP and its Chief...plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc.… more