- Commonwealth Care Alliance (Boston, MA)
- 011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider ... network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider… more
- Commonwealth Care Alliance (Boston, MA)
- …staff, including nurse reviewers and support personnel. - Act as liaison with medical director , provider relations, case management and quality teams to support ... Management (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care… more
- Humana (Topeka, KS)
- …a part of our caring community and help us put health first** The Corporate Medical Director (CMD) relies on medical background to review health claims ... and preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate… more
- Sanford Health (Sioux Falls, SD)
- …and grievances processing. Collaborate with legal, compliance, operations, and medical management teams to address complex cases and ensure proper resolution. ... complaints, and grievance processes across all product lines, including ACA, Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures adherence to… more
- Molina Healthcare (Lincoln, NE)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care....experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... for all of Sharp Health Plan products, (Commercial, Exchange, Medicare , POS/PPO) services, and oversees the health care needs...+ 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons… more
- UCLA Health (Los Angeles, CA)
- …Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan. In this key ... leadership role, you'll work closely with the UHMAP Medical Director and play a vital part...policy that's grounded in the latest scientific research and Medicare guidelines. Your work will directly support our Health… more
- Molina Healthcare (Albuquerque, NM)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care....experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- State of Colorado (Jefferson County, CO)
- ASSISTANT DIRECTOR OF NURSING - MID-LEVEL PROVIDER Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5120453) Apply ASSISTANT DIRECTOR OF ... Colorado. Admissions are for individuals with complex behavior and medical needs who may pose a risk to themselves...local Health Departments. This position is accountable to the Director of Nursing (DON). This full-time position sits on… more
- Dignity Health (Bakersfield, CA)
- …to the Medical Director of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related ... offices primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… more
- Commonwealth Care Alliance (Boston, MA)
- 011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider ... network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider… more
- Molina Healthcare (San Bernardino, CA)
- …corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more
- Elevance Health (Atlanta, GA)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision....final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. +… more
- State of Colorado (Golden, CO)
- …security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to ... professional development training (as available) + Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Denver, CO)
- …security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- Mary Greeley Medical Center (Ames, IA)
- …and meet regulatory requirements. + Reports any observed or suspected deviation from medical center policies or from Medicare , Medicaid, or other insurance ... regulations immediately to the department Manager, Director , or the medical center's Compliance Officer....Compliance Officer. + Reports any concerns regarding patient care grievances to the Manager or Director . +… more
- Peak Vista (Colorado Springs, CO)
- …programs and education. We provide integrated health care services including medical , dental, and behavioral health through our 20 outpatient health centers. ... be prorated for PT employees. Summary of Benefits: + Medical , Dental, Vision, Life, STD, LTD + 403(b) Retirement...outcomes. + Provide timely updates and reports to the Director of Population Health, QI Committee, Executive Team, and… more
