- 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
- 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
- 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 (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
- 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
- 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
- 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
- Highmark Health (Salem, OR)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… 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
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The Medical Director , Utilization Management is responsible for assuring physician...health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment… more
- State of Colorado (Denver, CO)
- …employment laws; progressive discipline; records management; recruitment; responding to grievances , appeals , charges of discrimination; reorganization issues; ... of Job This position is currently hybrid. 3 days remote , 2 days in office Please note: These working...Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals… more
- State of Colorado (Pueblo, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Golden, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... professional development training (as available) + Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... after the initial training period. The FWA includes a hybrid workplace which is partly remote (work from home) and two (2) days per week in office at a satellite… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the general function… more
- State of Colorado (Pueblo, CO)
- …State Personnel Board (https://spb.colorado.gov/) or request a review by the State Personnel Director . You will find the appeals process, theofficial appeal form ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... performance plans, corrective and disciplinary actions, assist resolving informal grievances , staff scheduling, position descriptions, recruitment, retention, interviewing and… more
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