- Sanford Health (Sioux Falls, SD)
- …governing appeals and grievance resolution. Lead and manage the end-to-end appeals and grievances process for all product lines, ensuring compliance with ... state requirements. Oversee the intake, review, resolution, and documentation of all appeals , complaints, and grievances to meet regulatory and operational… more
- Elevance Health (Atlanta, GA)
- …to Medical Director for final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external review. + Research to...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Molina Healthcare (Lincoln, NE)
- …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
- Molina Healthcare (Detroit, MI)
- …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 investigation of adverse… more
- Commonwealth Care Alliance (Boston, MA)
- …of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the ... schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and… more
- State of Colorado (Jefferson County, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ASSISTANT DIRECTOR OF NURSING - MID-LEVEL PROVIDER Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5120453) Apply ASSISTANT DIRECTOR OF… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP)… 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 ... you passionate about evidence-based medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage...is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan.… more
- Molina Healthcare (Albuquerque, NM)
- …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
- State of Colorado (Grand Junction, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Behavioral Site Director (Health Professional V) - Grand Junction Regional...staff, including hiring, training, evaluations, disciplinary actions, and resolving grievances . - Direct staff resources to ensure effective delivery… more
- CVS Health (Tallahassee, FL)
- …oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for ... UM and participate in UM front line work and appeals in markets as needed. * Confer directly with...peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage… more
- Dignity Health (Bakersfield, CA)
- … of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related duties. **Job Requirements** ... primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing and driving… more
- Fallon Health (Worcester, MA)
- …of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and ... be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for...assigning all incoming appeals and grievances… more
- Cognizant (Carson City, NV)
- …or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews . ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- State of Colorado (Golden, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... professional development training (as available) + Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Golden, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the general function… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the general function… more
- State of Colorado (Golden, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... hygiene practice. Ensure that youth are provided confidential access to grievances , medical assistance and mental health assistance as needed/requested without staff… more
- Cedars-Sinai (Beverly Hills, CA)
- …the payor + Investigates, processes and assists with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate ... than date of discharge. + Communicates with CSMPN Medical Director , Employee Health Services, Risk Management, and TPA +...inpatient or outpatient settings preferred; knowledge of HMO and Medicare rules in inpatient, home health and at the… more