- AmeriHealth Caritas (Philadelphia, PA)
- …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
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA- Appeals & Grievances **Position Summary:** Appeals and Grievances Program Advisor monitors and supports the operations and compliance of the ... Appeals and Grievances department through many NCQA and other related quality program activities including: monthly case quality monitoring, coordination of… more
- Fallon Health (Worcester, MA)
- …other applicable regulatory requirements and member and provider expectations. The FH Appeals and Grievances Triage Administrator serves to administer the FH ... The Triage Administrator is responsible for triaging and assigning all incoming appeals and grievances addressed to the Member Appeals & Grievances … more
- Healthfirst (NY)
- **Duties and Responsibilities:** + Conduct quality audits of A&G items cases grievances , pre-service appeals , and post service appeals utilizing appropriate ... information required to complete the audit. + Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully… more
- Healthfirst (NY)
- + Conduct quality audits of A&G items including grievances , pre-service appeals , and post service appeals utilizing appropriate sources of information; ... processes and performance to ensure quality. + Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and… more
- Humana (Topeka, KS)
- …a part of our caring community and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by conducting ... and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer… more
- Elevance Health (Seattle, WA)
- …be considered. **Expected Work Hours:** Monday-Friday; 8am-5pm PST The **Manager II Grievance/ Appeals ** is responsible for management oversight of grievances and ... appeals departmental units to investigate, resolve, and respond to grievances and appeals , manages inventory and production levels, and operational and plan… more
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA- Appeals & Grievances **Position Summary** Appeals and Grievances Specialist supports the Operations Department and the Appeals and ... as well as externally to facilitate timely resolution of all grievances and appeals and ensures compliance with regulations. Additionally, this position is… more
- Corewell Health (Grand Rapids, MI)
- …+ Ensure that the Appeals & Grievance department processes all appeals , grievances , and complaints in accordance with standards and the organization's ... are up to date with regulatory, departmental, and organizational changes impacting the appeals and grievances processes. + Supervise the day-to-day operations of… more
- Motion Recruitment Partners (Durham, NC)
- …Be Doing** + Analyze, research, resolve and respond to confidential/sensitive appeals , coding disputes, grievances and coverage/organization determinations from ... review organizations, benefit panels and external medical consultants. + Provide comprehensive appeals , coding disputes and grievances responses that support the… more
- Centene Corporation (Phoenix, AZ)
- …and authorization appeals from providers and pursue resolution of formal grievances from members. + Gather, analyze and report verbal and written member and ... provider complaints, grievances and appeals + Prepare response letters for member and provider complaints, grievances and appeals + Maintain files on… more
- Point32Health (MA)
- …responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for ... to organize, plan and implement the functions of Member Appeals and Grievances , maintain timelines and turnaround times to meet multiple requirements/regulations… more
- Baylor Scott & White Health (Temple, TX)
- … Appeals and Grievance Coordinator is responsible for intake into the Appeals and Grievances Department, including verbal and written complaints, ... grievances and requests for appeals that involve complex matters submitted by Members and...written and fax referred cases from member and provider appeals and complaints for all lines of business, ensuring… more
- CareFirst (Baltimore, MD)
- …process with dynamic goals resulting in the full and fair review of appeals and grievances designed to achieve corporate objectives and advance departmental ... and accreditation requirements. Ensures appropriate and complete resolution of appeals , Regulatory complaints and External review requests. Performs analytics and… more
- Humana (Sacramento, CA)
- …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and… more
- Humana (Topeka, KS)
- …Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the appropriateness and medical necessity of services provided by other healthcare professionals in compliance with coverage… more
- Elevance Health (Wallingford, CT)
- …that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (ie member, provider, ... you will make an impact:** + Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory… more
- Evolent (Des Moines, IA)
- …**Required** + Minimum of 5 years in Utilization Management, health care Appeals , compliance and/or grievances /complaints in a quality improvement environment- ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of… more
- Centene Corporation (Tallahassee, FL)
- …is hired, based on business need. Job specific responsibilities: + Pharmacy Grievances , Appeals , and Prior Authorizations + Processing Pharmacy Appeals ... benefits including a fresh perspective on workplace flexibility. **Pharmacy Coordinator ( Appeals ) - Florida** **Position Purpose:** Perform duties to support the… more
- Humana (Austin, TX)
- …health first** The Resolution team handles all complaints for Humana, including formal grievances , appeals , inquiries and disputes. Our mission is to resolve ... and providers. As the Resolution Team Operations Director (Director, Grievance and Appeals ), you will be accountable for the day-to-day operations and performance of… more
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