- Stanford Health Care (Palo Alto, CA)
- …America) **This is a Stanford Health Care job.** **A Brief Overview** The Director of Reimbursement is a key leadership role within the Controller's Office, ... and regulatory reports to government agencies, including but not limited to: - Medicare and Medi-Cal cost reports -Financial disclosures to the Department of Health… more
- CVS Health (Hartford, CT)
- …in the US. **Responsibilities of this Medical Director role are related to Medicare Appeals :** * Direct daily work on part C appeals (both provider ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal...Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. *… more
- Humana (Topeka, KS)
- … (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… more
- Sanford Health (Sioux Falls, SD)
- …oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, including ACA, ... Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures...all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …states (ME, NH, VT, MA, RI, CT) Under the general supervision of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced ... determine if an appeal is warranted. + Formulate clinical appeals and letters of medical necessity to...trends; including denials that have been escalated to the Medicare Administrative Law Judge (ALJ). + Represent DFCI at… more
- Elevance Health (Atlanta, GA)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... Appeals ** is responsible for investigating and processing and medical necessity appeals requests from members and...or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.… more
- WMCHealth (Valhalla, NY)
- …the monies lost to insurance companies due to denials. Generate appropriate appeals , both retrospective and concurrent, based on medical necessity criteria. ... Denials and Appeals Mngmt Cord Company: WMC Advanced Physician Services...change from time to time. + Review and identify medical necessity denials appropriate for appeal. + Appeal appropriate… more
- Cognizant (Washington, DC)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member… more
- Beth Israel Lahey Health (Charlestown, MA)
- …a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will perform high-level clinical ... gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in order to prove... relevant to the audits in order to prove medical necessity and level of care were warranted in… more
- CVS Health (Sacramento, CA)
- …of covered benefits in the Commercial and Medicare environment with a focus Medicare policy., This Medical Director provides subject matter expertise in ... CVS Health company, has an outstanding opportunity for a Medical Director . Ready to take your career...of Aetna clinical and coding policy and experience with appeals , claim review, reimbursement issues, and coding is preferable,… more
- CommonSpirit Health (Englewood, CO)
- …and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate ... are seeking a highly skilled individual to develop and submit clinical appeals , expertly crafting physician-aligned letters based on federal and state regulations,… more
- Molina Healthcare (Lincoln, NE)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Elevance Health (Miami, FL)
- ** Medical Director - Florida Medicare ...the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... must reside in Florida near our Miami or Tampa locations.** The ** Medical Director ** will support the following Florida Medicare plans: Simply Healthcare… more
- Centene Corporation (Jefferson City, MO)
- …including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical ... with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including… more
- OhioHealth (Columbus, OH)
- …Manager with updates. CGS audits and auditors Working with our legal vendor for Medicare Appeals . Working with OHA and CBSA facilities on wage index ... matter expert in the following areas, S-10, Wage Index, Bad Debts, Medicare Audits, Disproportionate Share, Indirect Medical Education, Graduate Medical… more
- Houston Methodist (Katy, TX)
- …medical coding, insurance billing, collections, patient account resolution, appeals /denials, customer service, cash applications, revenue integrity, etc. This ... procedures, and provides quality reviews. Reports results of key performance metrics to director on a timely basis. **FINANCE ESSENTIAL FUNCTIONS** + Assists in the… more
- Humana (Topeka, KS)
- **Become 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 work assignments involve moderately complex to complex issues...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Fortune 6 company, has an outstanding opportunity for a Medical Director - Medical Affairs...individual client requested coverage determinations or appeals when appropriate. - Medical Directors will… more
- Humana (San Juan, PR)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes reviewing of all… more
- Humana (Indianapolis, IN)
- **Become 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 work assignments involve moderately complex to complex issues...group practice management. + Utilization management experience in a medical management review organization, such as Medicare … more
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