- Molina Healthcare (Orlando, FL)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- Evolent (Tallahassee, FL)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a meaningful impact ... as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to… more
- Evolent (Tallahassee, FL)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- DOCTORS HEALTHCARE PLANS, INC. (Coral Gables, FL)
- Onsite Position Position Purpose: Works in partnership with physicians, nurse case managers, and other disciplines to ensure the appropriateness for the ... in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management/Medical Director in the appeals process. + Responsible… more
- Molina Healthcare (Miami, FL)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Elevance Health (Tampa, FL)
- …will make an impact:** + Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care. + Perform ... physician-level case review, following initial nurse review, of chemotherapy regimens. + Determine medical necessity...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more
- CVS Health (Tallahassee, FL)
- …in accordance with contract. -Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) ... to incoming correspondence and internal referrals. -Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. -Performs… more
- Sharecare (Tallahassee, FL)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more