- Sanford Health (Sioux Falls, SD)
- …related field required. Master's degree preferred. Minimum of 7 years of experience in health plan appeals and grievances , regulatory oversight, or health ... Strong knowledge of CMS, Medicaid, ACA, and Commercial appeals and grievances regulations. **Benefits** Sanford Health offers an attractive benefits package… more
- AmeriHealth Caritas (Philadelphia, PA)
- …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
- CVS Health (Tallahassee, FL)
- At CVS Health , we're building a world of health ...UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers ... and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we… more
- AmeriHealth Caritas (Washington, DC)
- …Management, Program Integrity, Risk Adjustment, Provider Resolution Team, Provider Appeal and Grievances , Member Appeals and Grievances , Network adequacy and ... **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the...toward financial sustainability and identify opportunities for improved profitability, health outcomes, and risk adjustment goals; directs analytical activities… more
- UCLA Health (Los Angeles, CA)
- …+ Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Support day-to-day UM and Clinical ... medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage Plan is looking for a dedicated...is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan.… more
- Dignity Health (Bakersfield, CA)
- …efficiency, and address impactable variation. - Serve as the physician medical director for the Population Health Services Organization (PHSO) quality division. ... of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related duties. **Job Requirements**… more
- Washington County Mental Health Services (Barre, VT)
- Senior Director of Quality Assurance and Compliance Washington County Mental Health Services is seeking an experienced Senior Director of Quality Assurance ... Identify and mitigate compliance and quality risks through proactive measures, manage Grievances and Appeals processes, and conduct routine assessments of… more
- Fallon Health (Worcester, MA)
- …or follow us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's ... be able to type 25 WPM.** **About us:** Fallon Health is a company that cares. We prioritize our...departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible… more
- Molina Healthcare (Tampa, FL)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- City of New York (New York, NY)
- …and administer the contractual grievance process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before ... planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy… more
- Herkimer County Community College (Herkimer, NY)
- …and serve as the lead administrator for negotiations with bargaining units. Facilitate grievances and employee appeals related to working conditions and contract ... Job Description: Herkimer College is seeking qualified applicants for a full-time Director of Human Resources. This position provides overall coordination of human… more
- Highmark Health (Tallahassee, FL)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... + None **Preferred** + Master's Degree in Business Administration/Management or Public Health **EXPERIENCE** **Required** + 5 years in Clinical, Direct Patient care… more
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization… more
- Molina Healthcare (Fort Worth, TX)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * Supports...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… 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...for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health Plan members.… 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. * Develop and ... coverage while working remotely. Primary Responsibilities * Performs behavioral health clinical utilization reviews using evidenced based guidelines, policies and… more
- State of Colorado (Jefferson County, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... HEALTH CARE TECHNICIAN IV - Residential Coordinator for...reviews (PMPs). + Determines and responds to Step 1 grievances if staff supervised initiates a formal grievance. +… more
- Cognizant (Annapolis, MD)
- …and responsibility for assigned accounts. . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well ... delays in payment. . Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in… more
- State of Colorado (Canon City, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... "Safety Officers" and are eligible for increased PERA benefits. + Medical and dental health plans + Short and long term disability coverage + Paid life insurance +… more
- State of Colorado (Golden, CO)
- …data for health program planning. Consults with the DYS Medical Director for necessary referrals to other physicians and specialists for medical, dental and ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more