- 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 ... Oversee the intake, review, resolution, and documentation of all appeals , complaints, and grievances to meet regulatory...and documentation of all appeals , complaints, and grievances to meet regulatory and operational standards. Ensure all… 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… more
- 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
- 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
- Elevance Health (Costa Mesa, CA)
- …. + Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination. + Ensures grievances are resolved timely to ... **Nurse Appeals RN-Quality of Care** **Location: California-Costa Mesa, Walnut...limited to: + Conducts investigations and reviews of member grievances and Quality of Care cases. + Reviews medical… more
- Elevance Health (Metairie, LA)
- …. + Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination. + Ensures grievances are resolved timely to ... **Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role...limited to: + Conducts investigations and reviews of member grievances and Quality of Care cases. + Reviews medical… more
- Cognizant (Washington, DC)
- …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
- 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 ... business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp...trends in grievances . Supervises the process for identifying Potential Quality Issues.… 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
- Guardian Life (Plano, TX)
- …compliant with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and ... The **Dental Director ** will be responsible for ensuring that professional...& ensure that determination and processing of claims, referralsand appeals meet state regulations, time frames& definitions. + Completeadjudication… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage review, member… more
- Independent Health (Buffalo, NY)
- …and Medical Director . This position will prepare written responses to appeals and complaints/ grievances , establish plans of correction and provide education ... for the collection and review of medical records specific to quality complaints/ grievances and appeals as indicated in support of a high performing health 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
- 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
- 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 ... is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan....leadership role, you'll work closely with the UHMAP Medical Director and play a vital part in developing and… 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
- 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 ... a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical...in grievances . Supervises the process for identifying Potential Quality Issues.… 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
- 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
- University of Miami (Coral Gables, FL)
- …review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . The Director , Faculty Affairs supports the Vice Provost for ... and leading process improvement initiatives for the OFA. The Director engages with the Vice Provost for Faculty Affairs,...Assists the Vice Provost in managing salary review and appeals . + Reviews and process Coral Gables and Rosenstiel… more
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