- Elevance Health (Woodbridge, NJ)
- ** Manager II Grievance / Appeals ** **- Claims Support** **Office Locations:** _The selected candidate must reside within a reasonable commuting distance of the ... employment, unless an accommodation is granted as required by law._ The ** Manager II Grievance & Appeals ** responsible for management oversight of grievances… more
- State of Colorado (Colorado Springs, CO)
- CDOC - Liaison III (Step 3 Grievance Responder) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5123844) Apply CDOC - Liaison III (Step 3 ... Grievance Responder) Salary $4,906.00 - $7,849.00 Monthly Location Colorado...establish an eligible list for referral to the hiring manager for final consideration. Use of artificial intelligence (AI)… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager , Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances Location: Los ... net required to achieve that purpose. Job Summary The Manager , Appeals & Grievances (A&G) & General...and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …guidelines including URAC, NCQA, and ERISA + Proficiency in Clinical Appeals , Utilization Review, and Grievance processes including benefit interpretation, ... clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit… more
- Elevance Health (Charlotte, NC)
- …by medical directors and consultants; preparing recommendations to uphold or deny appeals ; and ensuring all grievance processes are completed within regulatory ... paralegal experience is strongly desired. + Understanding of the grievance and appeals process is strongly preferred....Strategy. Unless specified as primarily virtual by the hiring manager , associates are required to work at an Elevance… more
- Molina Healthcare (South Charleston, OH)
- …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... Manages staff responsible for the submission/resolution of member and provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant. +… more
- Elevance Health (Atlanta, GA)
- **Nurse Appeals ** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing ... between those hours, including holidays on a rotational basis. The **Nurse Appeals ** is responsible for investigating and processing and medical necessity appeals… more
- Elevance Health (Costa Mesa, CA)
- **Nurse Appeals RN-Quality of Care** **Location: California-Costa Mesa, Walnut Creek, or Woodland Hills** **Hybrid 1:** This role requires associates to be in-office ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Pacific Standard Time The **Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- Elevance Health (Metairie, LA)
- **Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time The **Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- Fallon Health (Worcester, MA)
- …us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance ... standards, other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH… more
- Transdev (Dorchester, MA)
- Overview: Transdev in Boston, MA is seeking a Labor Relations Manager for its Boston Public Schools transportation contract. The Labor Relations Manager provides ... Responsibilities: + Manage labor relations program of the property jointly with the General Manager . + Research, compile, and prepare data for use in grievance … more
- CVS Health (Des Moines, IA)
- …and every day. **Position Summary** Plans and executes strategies to meet the Grievance & Appeals organization's long-range goals. Evaluates and develops new ... initiatives and analyzes business opportunities. Develops proposals, including feasibility studies, for new opportunities. Identifies, analyzes and compares alternative opportunities for solutions and adopting new technologies. + Acts as a top-level specialist… more
- LA Care Health Plan (Los Angeles, CA)
- …all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters ... collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory… more
- Clark County, NV (Las Vegas, NV)
- …and Labor Relations team and report to the Employee and Labor Relations Manager . This examination will establish an Open Competitive Eligibility list to fill current ... and provisions of agreements with employee organizations; monitors and facilitates grievance and dispute resolution processes and attempts to effect equitable… more
- Sharp HealthCare (San Diego, CA)
- …Chief Medical Officer and reports findings in conjunction with the Quality Improvement Manager . + Participates in the grievance process with the Chief Medical ... policy as needed. + Completes and/or supervises the completion of all clinical appeals and grievances. Collaborates with Customer Care Manager to identify trends… 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 ... needs of the membership. Serves as a lead medical manager and policy advisor to SHP clinical and its'...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- Guardian Life (Plano, TX)
- …with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and definitions for ... Review & ensure that determination and processing of claims, referralsand appeals meet state regulations, time frames& definitions. + Completeadjudication of retail… more
- State of Colorado (Denver, CO)
- …referrals and consultations, medical reporting, medical co-signature and inmate grievance requirements are completed in accordance with DOC Administrative ... establish an eligible list for referral to the hiring manager for final consideration. Be sure the "Work Experience"...of the department's action. For more information about the appeals process, the official appeal form, and how to… more
- Elevance Health (Morristown, NJ)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations....Strategy. Unless specified as primarily virtual by the hiring manager , associates are required to work at an Elevance… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …referrals generated to care management programs + Provides administrative support to the grievance and appeals process within the + Medical Services department ... functions assigned to non-care managers are monitored by the care manager + The care manager provides feedback to the non-care manager 's supervisor, as… more
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