- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances , the Manager, Appeals & Grievances ... Oversight is responsible for the oversight of Plan level appeals and grievances within the Appeals...to the policies and procedures as assigned by the Director . Partner with A&G Operations Manager and the A&G… more
- Humana (Boston, MA)
- … 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
- Highmark Health (Boston, MA)
- …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
- Beth Israel Lahey Health (Westwood, MA)
- …address information. Escalates calls to pharmacists for clinical inquiries and escalates grievances to supervisor. 7. Maintains new and existing patient profiles and ... Support health care providers with required prior authorization and required appeals . Manage all mail/delivery of Rx orders including addressing problems/issues with… more