- Molina Healthcare (Long Beach, CA)
- …reviews and recommends corrective actions. Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. ... for medical necessity. Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of… more
- NORTH EAST MEDICAL SERVICES (San Francisco, CA)
- …including participation in regional or national geriatric societies. Reviews all appeals and grievances . Coordinates quality assurance activities including the ... Range $285229.20 - $332260.24 Salary Description The PACE Medical Director is responsible for the management and oversight of...other staff assigned to his/her team. The PACE Medical Director oversees the clinical care provided by the NEMS… more
- CenCal Health (Santa Barbara, CA)
- …management functions; assists subordinate managers in resolving medical claims review, grievances , appeals , and other medical management issues Works closely ... Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, care… more
- Veracity Solutions (Kennewick, WA)
- …problems, such as: working conditions, disciplinary actions, and employee and applicant appeals and grievances , according to circumstances, and provides guidance ... People Services, Director Kennewick, WA 99336 Full Time Must-Haves Candidate...as needed. *Provides high level communication and training to director and manager level associates regarding human resources policies,… more
- Molina Healthcare (St. Petersburg, FL)
- …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
- Molina Healthcare (San Antonio, TX)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and… more
- Humana (Carson City, NV)
- …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
- Elevance Health (Tampa, FL)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Accounting/Finance Department: CSC Appeals & Grievances ... net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for… 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: ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the...staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in… more
- Humana (Little Rock, AR)
- … 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… more
- UPMC (Pittsburgh, PA)
- …seeking a board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This role is ... choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician commitment and… more
- Molina Healthcare (Tampa, FL)
- …and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and quality functions. You ... entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & Resolution you set the...Workflow Integration - Embed CTM insights into downstream operations-Stars, appeals & grievances , enrollment, claims-so each team… more
- State of Colorado (Pueblo, CO)
- …appeal with the State Personnel Board or request a review by the State Personnel Director . You will find the appeals process, the official appeal form, and how ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… 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
- Excellus BlueCross BlueShield (Buffalo, NY)
- …on the Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) ... care system. + Develops, conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as… 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
- Somatus (Mclean, VA)
- …physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for ... of business including Commercial, Medicaid, Medicare, and Special Need Plans (SNPs). The Director , Quality will work closely with Sr. Manager, Audit Risk and the… more
- Molina Healthcare (Santa Fe, 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
- Trinity Health (Gaithersburg, MD)
- …all activities pertaining to complaints, service delivery requests, and grievances / appeals , assures regulatory compliance and incident reporting including ... **Employment Type:** Full time **Shift:** Day Shift **Description:** ** Director , Quality, Improvement and Compliance** **Location:** Trinity Health PACE of… more
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