- Molina Healthcare (Long Beach, CA)
- …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....relevant experience, including: 2 years previous experience as a Medical Director in a clinical practice. Current… more
- Sante Health (Fresno, CA)
- NOT A REMOTE POSITION. A challenging and rewarding opportunity awaits a new Director of Quality Management at Sante Health System in Fresno, CA. This leadership role ... partners closely with health plans and medical providers to analyze data, identify trends, and develop...outcomes across Sante's ACO, HMO, and PPO populations. The Director will oversee and drive quality improvement initiatives, enhance… more
- CenCal Health (Santa Barbara, CA)
- …Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, ... leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances , appeals, and other medical … more
- City of El Segundo, CA (El Segundo, CA)
- …AND EXERCISED: Receives general supervision from the Community Development Director . Provides direct supervision to administrative, technical and support staff. ... and standards; initiates corrective and/or disciplinary action and responds to grievances and complaints according to established personnel policies and procedures… more
- Southern Oaks Care Center (Pawnee, OK)
- …pre-certifications and recertifications in accordance with facility policies for Medicare Advantage and commercial insurance payers. Interpret the department's ... coding for accuracy. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Periodically… more
- University of Minnesota Physicians (Minneapolis, MN)
- …is seeking a part-time (30%; 0.1cFTE, 0.2aFTE) Assistant Professor Program Director highly committed to the exceptional training of Addiction Medicine fellows. ... Addiction Medicine Fellowship program with four fellows. Job Duties/Responsibilities: The Program Director is provided with 0.2 aFTE, one day per week, dedicated… more
- Humana (Carson City, NV)
- …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
- Molina Healthcare (St. Petersburg, FL)
- …3 years in a manager role. * Experience with Medicare Regulations, Medicare Duals, Appeals & Grievances , Provider Disputes (Par and Non-Par) and overall ... Summary** Responsible for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that is responsible for reviewing and… more
- Molina Healthcare (San Antonio, TX)
- …with the standards and requirements established by the Centers for Medicare and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the ... activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized… more
- Humana (Little Rock, AR)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews 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… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I (Temporary) Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center Appeals & Grievance… more
- Elevance Health (Tampa, FL)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... Medicare ** is responsible for investigating and processing and medical necessity appeals requests from members and providers. **How...to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that… 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
- Excellus BlueCross BlueShield (Buffalo, NY)
- …and implementation of the Children's Behavioral Health (BH) Carve-In program. The Medical Director for BH Children's Services has overall accountability for ... of the Quality Management/Utilization Management (QM/UM) Plan, including having the BH Medical Director for Children's Services and participate on the BH… more
- Molina Healthcare (Santa Fe, 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
- 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
- Somatus (Mclean, VA)
- …provides guidance and oversight to all lines of business including Commercial, Medicaid, Medicare , and Special Need Plans (SNPs). The Director , Quality will work ... the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional… more
- Trinity Health (Gaithersburg, MD)
- …The Director , Quality Improvement and Compliance, in collaboration with the Medical Director , is responsible for developing and implementing the annual QI ... implement the annual Quality Improvement (QI) Plan with the Medical Director + In conjunction with ...compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program.… 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
- State of Colorado (Pueblo, 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
