- Molina Healthcare (Kenosha, WI)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving...monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and… more
- AmeriHealth Caritas (Newark, DE)
- …more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the ... complaints/issues to management + Monitors to ensure that all problems with appeals / grievances presented by plan members/participants are resolved in accordance… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Administrative, HR, Business Professionals Department: CSC ... Appeals & Grievances Location: Los Angeles, CA,...This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as… more
- Humana (Topeka, KS)
- …Director (CMD) relies on medical background to review 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 regarding the appropriateness and… more
- Humana (Olympia, WA)
- … 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
- UPMC (Pittsburgh, PA)
- …seeking a board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This role is ... choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician commitment and… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp...trends in grievances . Supervises the process for identifying Potential Quality Issues.… more
- Sharp HealthCare (San Diego, CA)
- …policy as needed. + Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify trends ... a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical...in grievances . Supervises the process for identifying Potential Quality Issues.… more
- Insight Global (Norfolk, VA)
- Job Description Insight Global is looking for a Remote Director of Health Plan Business Testing for a large healthcare company. This individual must reside in ... one of the approved remote states listed below. This candidate will lead all...Claims, Encounters, Benefits Configuration, Claims & Pricing Configuration, Enrollment, Appeals & Grievances , and Contact Center/Customer Service.… more
- Highmark Health (Dover, DE)
- …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
- Oregon State University (Corvallis, OR)
- …Administrator 2-Contr & Compl Job Title Assistant Dean of Students and Director of Disability Access Services Appointment Type Professional Faculty Job Location ... Corvallis Benefits Eligible Full-Time, benefits eligible Remote or Hybrid option? Job Summary Disability Access Services...Services is seeking an Assistant Dean of Students and Director of Disability Access Services. This is a full-time… more
- UPMC (Pittsburgh, PA)
- The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The Medical Director , Utilization Management is responsible for assuring physician...health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Colorado Springs, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... youth grievance policy and procedure are followed. Review of grievances to include investigation, follow up and appropriate action...Board or request a review by the State Personnel Director . An appeal or review must be submitted on… more
- State of Colorado (Denver, CO)
- …appeal with the State Personnel Board or request a review by the State Personnel Director . You will find the appeals process, the official appeal form, and how ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
- Commonwealth Care Alliance (Boston, MA)
- …schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and ... 011250 CCA-Claims **_This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …multiple areas, including but not limited to UM and CM, Fair Hearings and Appeals / Grievances , within three months of working in position. + Demonstrates ability ... May be required to attend Fair Hearings with Medical Director relating to specific cases. + Works independently, as...paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the Excellus… more