- 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
- 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
- Cognizant (Washington, DC)
- …or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews . ... **Schedule:** Monday to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work… 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 (Indianapolis, IN)
- …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 (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
- AmeriHealth Caritas (Washington, DC)
- …Management, Program Integrity, Risk Adjustment, Provider Resolution Team, Provider Appeal and Grievances , Member Appeals and Grievances , Network adequacy and ... **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the.... **Our Comprehensive Benefits Package** Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time… 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
- UPMC (Pittsburgh, PA)
- The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… 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 (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 (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, ... 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, ... 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 (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 (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, ... practice. Ensure that youth are provided confidential access to grievances , medical assistance and mental health assistance as needed/requested...Board or request a review by the State Personnel Director . An appeal or review must be submitted on… 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, ... and disciplinary actions. + Addresses employee complaints and resolves informal grievances . + Positions start the hiring process, interview applicants, and recommend… 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, ... actions, signing performance plans and appraisals, and resolving informal grievances . Positions start the hiring process, interview applicants, and recommend… more
- Commonwealth Care Alliance (Boston, MA)
- …schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and ... 011250 CCA-Claims **_This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this… more
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