- Humana (Boston, MA)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims and ... preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Commonwealth Care Alliance (Boston, MA)
- 011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider ... network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more
- Cognizant (Boston, MA)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a... Medicare , Medicaid, and third-party guidelines. . Effectively document and… more