- LA Care Health Plan (Los Angeles, CA)
- …experience in a patient care setting and/or combination in utilization management , appeals and grievances , delegation oversight, and/or CNA experience. ... Utilization Management Nurse Specialist LVN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position… more
- Centers Plan for Healthy Living (Margate, FL)
- …in related area of responsibility, (ie utilization management , quality management , grievances , and appeals ) Type of Experience Required: Strong ... RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate,...handle expedited and standard requests and ensures that the appeals are processed in accordance with regulations, compliance standards… more
- System One (Baltimore, MD)
- …business knowledge of clinical operations, including Care Management , Utilization Management , and Appeals & Grievances . Previous experience using the ... with clinical operations, including Care Management , Utilization Management , and Appeals & Grievances . + Previous experience using the GuidingCare,… more
- LA Care Health Plan (Los Angeles, CA)
- …Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management , Pharmacy, and Quality Management ) to ... Manager, Customer Solution Center Appeals and Grievances Job Category: Customer...work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management , Quality Management , Pharmacy)… 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 ... Supervisor, Appeals and Grievances Clinical Operations RN...a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute for the supervisory/… more
- Elevance Health (Woodland Hills, CA)
- …+ The analyst may serve as a liaison between grievances & appeals and /or medical management , legal, and/or service operations and other internal ... that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (ie member, provider,… more
- Elevance Health (Louisville, KY)
- …+ The analyst may serve as a liaison between grievances & and appeals and /or medical management , legal, and/or service operations, and other internal ... Department that reviews analyzes and processes non-complex pre-service and post-service grievances and appeals requests from customer types (ie member,… more
- CareFirst (Baltimore, MD)
- …health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances . **Preferred Qualifications:** + Applicants with specific ... **Knowledge, Skills and Abilities (KSAs)** + Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and… more
- Fallon Health (Worcester, MA)
- …functions such as quality improvement, credentialing, member rights, utilization management , including member appeals and grievances to support ... them in accreditation compliance. + Implements cross functional teams to meet standard requirements for accreditation review and oversees the team's progress to ensure that timelines are met. + Coordinates and oversees onsite or virtual accreditation and audit… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …review of services and care. * Provides referrals to Case management , Disease Management , Appeals & Grievances , and Quality Departments as needed. * ... About The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical… more
- Hackensack Meridian Health (Hackensack, NJ)
- …standards, and regulatory/payor requirements. The role integrates and coordinates utilization management , care coordination, discharge planning functions and ... of positive change. Supervises assigned staff to ensure that all case management processes are in order; including coordinating patient activities to ensure that… more
- Sharecare, Inc. (Columbus, OH)
- …open enrollment / new hire plan selection, claims issues, ID card issues, grievances / appeals , utilization management (UM) status, including but ... or 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex pharmacy inquiries +… more
- Ventura County (Ventura, CA)
- …Thorough knowledge of: mental health and substance abuse assessment, treatment, and case management practices; grievances , appeals and notices of actions; ... the state and federal governing entities, and resolves, tracks, and monitors grievances , appeals and Notices of Actions. This position continually collaborates… more
- Healthfirst (AL)
- …practice with experience in appeals & grievances , claims processing, utilization review or utilization management /case management . + Demonstrated ... appeals while helping standardize and optimize how Appeals and Grievances are routed + Manage...virtual filing systems (ie. Macess), and experience with care management systems, such as CCMS, TruCare and Hyland. **Preferred… more
- The Cigna Group (Nashville, TN)
- …**Job Requirements include, but not limited to:** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part C ... Medicare appeals and related issues, implications and decisions. The Case Management Analyst reports to the Supervisor/Manager of Appeals and will coordinate… more
- Highmark Health (Charleston, WV)
- …standards, and practitioner/provider education. The incumbent is an integral part of the utilization management team and assists utilization management ... State of West Virginia **ESSENTIAL RESPONSIBILITIES** + Communicate effectively. + Review utilization management cases and communicate the decisions to the… more
- LA Care Health Plan (Los Angeles, CA)
- …daily care management functions including care team rounds. Review of appeals , grievances and provider disputes. Provide strategic and operational leadership ... Director, Medical Management Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US,...of care, complex care rounds, interdisciplinary care team rounds, appeals and grievances and provider disputes. On… more
- Medical Mutual of Ohio (OH)
- …a Registered Nurse, including 1 year in a clinical quality review nurse role, care management , utilization management , medical case review or similar role. + ... complaints and quality cases per policy/NCQA/CMS guidelines.** + **Collaborates with Appeals & Grievances , Population Health, Provider Contracting, Customer Care… more
- Molina Healthcare (Bothell, WA)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical...analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory,… more
- AdventHealth (Maitland, FL)
- …and changes related to Care Management ..Serves as a member of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and ... experience **_E_** **_XPERIENCE_** **_P_** **_REFERRED_** _:_ . Understanding of Hospital Care Management , including Utilization Management . Two years or… more