- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...documented on all patient medical records. 6. Coordinates with Care Management team when cases do not… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals / Care /Case/Utilization Management /Quality. Strong verbal and written ... in Nursing Experience Required: Minimum of 8 years of acute/ clinical care experience. Minimum of 2 years...in a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute… more
- Trinity Health (Farmington Hills, MI)
- …length of stay, level of care , missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed ... causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals...experience, to include two (2) years of utilization review/case management , managed care or comparable patient payment… more
- Centene Corporation (IA)
- …LPN/LVN with 5+ years of clinical nursing or case management experience. Managed care or utilization review experience preferred. **License/Certification:** ... changes everything for our 28 million members as a clinical professional on our Medical Management /Health Services...report verbal and written information regarding member and provider clinical appeals , including information follow up +… more
- HCA Healthcare (San Antonio, TX)
- …our HCA Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Clinical Appeals Nurse RN with Parallon you can be a part of an ... and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. +...in our organization. We are looking for an enthusiastic Clinical Appeals Nurse RN to help us… more
- Penn Medicine (Philadelphia, PA)
- …of the Clinical Appeals Coordinator in all phases of the Clinical Quality and Utilization Management functions including but not limited to data entry, ... your life's work? **Summary:** Responsible for coordinating office activities for the Clinical Appeals Coordinators to assist the department in accomplishing the… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, June 3, 2024 Centers Plan for Healthy Living's goal is to ... a managed care environment in related area of responsibility, (ie utilization management , quality management , grievances, and appeals ) Type of Experience… more
- Martin's Point Health Care (Portland, ME)
- …well as other internal teams and external partners to ensure a comprehensive appeals management process. Medicare Focus Key Outcomes: + Processes, researches, ... the Medicare subject matter expert for the Medicare Managed Care Manuals pertaining to Part C appeals ...providers and third-party administrators. + Prepares case files on clinical member and provider appeals for review… more
- Texas Health Resources (Arlington, TX)
- …**What You Will Do** + Communicates and collaborates as needed with physicians, Care Management staff, Business Office, Nursing, and ancillary departments to ... ** Clinical Reviews, Denial and Appeals RN**...+ Serves as an educator and resource to the Care Management Staff, Physicians and other hospital… more
- LA Care Health Plan (Los Angeles, CA)
- …and specialist concerning follow care related to care management . (15%) Maintain the monthly reporting responsibilities, Appeals and Grievance reporting ... Grievance Specialists by handling the administrative functions of the care management /continuity of care process...non- clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care… more
- CVS Health (Columbus, OH)
- …educational interventions.* Work with medical director teams focusing on inpatient care management , clinical coverage review, member appeals clinical ... and other complex health populations to optimize risk adjustment, clinical quality, and care management .*...review, medical claim review, and provider appeals clinical review. * Actively participate in scheduled team meetings… more
- Universal Health Services (Chicago, IL)
- …SUMMARY: Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals , Standard Appeals , External ... Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally recognized criteria to… more
- Kepro (Indianapolis, IN)
- …health solutions in the public sector. Acentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our growing team. Job Summary: ... Our Utilization Management Appeals Nurse - LPN/RN will help...of Indiana or a Compact license. + Previous healthcare/managed care Appeals experience. + 2+ years of… more
- Trinity Health (Darby, PA)
- …with the RN Care Coordination Manager, provides support to the utilization management , denials and appeals process for the THMA South hospitals. The ... **Employment Type:** Full time **Shift:** Day Shift **Description:** The Appeals and Utilization Management Coordinator under direction and in collaboration… more
- LA Care Health Plan (Los Angeles, CA)
- …in a consistent and accurate manner. This position will focus on quality review of non- clinical grievance and appeals cases for all line of business (LOB) to ... Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job...$87,342.00 (Mid.) - $107,498.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created… more
- Banner Health (AZ)
- **Primary City/State:** Arizona, Arizona **Department Name:** Grievances & Appeals **Work Shift:** Day **Job Category:** General Operations The future is full of ... and skills to BPN. As a Senior Grievance & Appeals Coordinator you will call upon your years of...for compliance.** Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care… more
- Fallon Health (Worcester, MA)
- …a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon ... Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top...nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences,… more
- Magellan Health Services (San Diego, CA)
- Coordinates appeals process as assigned, attends to risk management issues associated with case management and processes appeal requests. In some cases may ... day compliance of appeal decision time frames. + Reviews clinical and medical records for completeness and determines administrative...medical necessity reviews. + Enters all data related to appeals and case reviews into a database. + Prepares… more
- CVS Health (Hartford, CT)
- …Utilization Management Staff* Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency Required Qualifications * Two ... system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.**This is a… more
- CareFirst (Baltimore, MD)
- … Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead ... week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical ...Licensure And/or Compact State Licensure. **Experience:** + 8 years clinical experience in care management .… more