- Sanford Health (Sioux Falls, SD)
- …related field required. Master's degree preferred. Minimum of 7 years of experience in health plan appeals and grievances , regulatory oversight, or health ... Strong knowledge of CMS, Medicaid, ACA, and Commercial appeals and grievances regulations. **Benefits** Sanford Health offers an attractive benefits package… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Administrative, HR, Business Professionals Department: CSC ... Appeals & Grievances Location: Los Angeles, CA,...(Mid.) - $107,498.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created by… more
- AmeriHealth Caritas (Newark, DE)
- …more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the ... complaints/issues to management + Monitors to ensure that all problems with appeals / grievances presented by plan members/participants are resolved in accordance… more
- Humana (Topeka, KS)
- …The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the appropriateness and… more
- Humana (Olympia, WA)
- …first** The Corporate Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of… more
- UPMC (Pittsburgh, PA)
- …board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This role is fully ... choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician commitment and… more
- Sharp HealthCare (San Diego, CA)
- …more years of clinical practice of medicine. + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical ... **Facility:** Health Plan **City** San Diego **Department** **Job Status**...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- Sharp HealthCare (San Diego, CA)
- …policy as needed. + Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify trends ... **Facility:** Health Plan **City** San Diego **Department** **Job Status**...a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical… more
- UCLA Health (Los Angeles, CA)
- …+ Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Support day-to-day UM and Clinical ... medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage Plan is looking for a dedicated...is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan.… more
- Trinity Health (Pensacola, FL)
- …all activities pertaining to complaints, service delivery requests, and grievances / appeals , assures regulatory compliance and incident reporting including ... the PACE Organization (PO) and ensure overall CMS regulatory compliance. The Director , Quality Improvement and Compliance, in collaboration with the Medical … more
- Fallon Health (Worcester, MA)
- …or follow us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's ... **Overview** **About us:** Fallon Health is a company that cares. We prioritize...departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible… more
- Somatus (Mclean, VA)
- …for our patients and partners. Showing Up for You We offer more than 25 Health , Growth, and Wealth Work Perks to help teammates learn, grow, and be the best ... physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for… more
- Insight Global (Norfolk, VA)
- Job Description Insight Global is looking for a Remote Director of Health Plan Business Testing for a large healthcare company. This individual must reside in ... include Claims, Encounters, Benefits Configuration, Claims & Pricing Configuration, Enrollment, Appeals & Grievances , and Contact Center/Customer Service. *… more
- Molina Healthcare (Idaho City, ID)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- City of New York (New York, NY)
- …and administer the contractual grievance process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before ... planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy… more
- Herkimer County Community College (Herkimer, NY)
- …and serve as the lead administrator for negotiations with bargaining units. Facilitate grievances and employee appeals related to working conditions and contract ... Job Description: Herkimer College is seeking qualified applicants for a full-time Director of Human Resources. This position provides overall coordination of human… more
- Oregon State University (Corvallis, OR)
- …Administrator 2-Contr & Compl Job Title Assistant Dean of Students and Director of Disability Access Services Appointment Type Professional Faculty Job Location ... Summary Disability Access Services is seeking an Assistant Dean of Students and Director of Disability Access Services. This is a full-time (1.00 FTE ), 12-month,… more
- Highmark Health (Dover, DE)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... + None **Preferred** + Master's Degree in Business Administration/Management or Public Health **EXPERIENCE** **Required** + 5 years in Clinical, Direct Patient care… more
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization… more
- Molina Healthcare (San Bernardino, CA)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * Supports...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… more