- State of Colorado (Colorado Springs, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... CDOC - Liaison III (Step 3 Grievance Responder) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5123844) Apply CDOC -...Board or request a review by the State Personnel Director . An appeal or review must be submitted on… more
- Sanford Health (Sioux Falls, SD)
- …strategic oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, ... adherence to all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end appeals and… more
- CVS Health (Hartford, CT)
- …remote based (work at home) based anywhere in the US. **Responsibilities of this Medical Director role are related to Medicare Appeals :** * Direct daily work on ... AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- AmeriHealth Caritas (Philadelphia, PA)
- …of medical management authorizations.; + Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial ... experience in a Managed Care environment + 1 to 3 years' experience in grievance / appeals environment required **The Ideal Person will have:** + Proven experience… more
- Elevance Health (Atlanta, GA)
- **Nurse Appeals ** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing ... between those hours, including holidays on a rotational basis. The **Nurse Appeals ** is responsible for investigating and processing and medical necessity appeals… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory ... appeal. **Work Arrangement:** + Hybrid in Philadelphia **Responsibilities:** + Process appeals , ensuring compliance with all regulatory milestones + Review medical… more
- Elevance Health (Costa Mesa, CA)
- **Nurse Appeals RN-Quality of Care** **Location: California-Costa Mesa, Walnut Creek, or Woodland Hills** **Hybrid 1:** This role requires associates to be in-office ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Pacific Standard Time The **Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- Elevance Health (Metairie, LA)
- **Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time The **Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- Humana (Topeka, KS)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- City of New York (New York, NY)
- …planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy ... arise with CFB employees. - Serve as the CFB's grievance representative and administer the contractual grievance ...process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before the Office… more
- Sharp HealthCare (San Diego, CA)
- …and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) ... 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- Guardian Life (Plano, TX)
- The **Dental Director ** will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. You ... will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and...report any quality-of-care issues. In addition, the State Dental Director will be expected to lend support to the… 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
- Humana (Indianapolis, IN)
- …not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic ... a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director … more
- Elevance Health (Morristown, NJ)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Medical Director ** **Medical Oncology** **Carelon Medical Benefit Management** **Virtual**...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more
- Sharp HealthCare (San Diego, CA)
- …physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical Board of CA ... from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains benchmarked utilization… more
- Humana (San Juan, PR)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations… more
- Fallon Health (Worcester, MA)
- …us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance ... standards, other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH… more
- Elevance Health (Costa Mesa, CA)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Associate Medical Director ** **Carelon Medical Benefits Management** **Radiology Benefit Management/Utilization Review** **Virtual** : This… more
- AmeriHealth Caritas (Washington, DC)
- **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the Market President, with oversight of operation services delivered by the ;Healthy DC ... Plan and all relevant federal, state, and local regulatory requirements. The Director Operations Healthy DC Plan is accountable for ensuring the plan's operating… more