- 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
- Humana (Honolulu, HI)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The ... Corporate Medical Director works on problems of diverse scope and complexity...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Possess analysis… more
- Sanford Health (Sioux Falls, SD)
- …and grievances processing. Collaborate with legal, compliance, operations, and medical management teams to address complex cases and ensure proper resolution. ... complaints, and grievance processes across all product lines, including ACA, Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures adherence to… more
- UCLA Health (Los Angeles, CA)
- …Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan. In this key ... leadership role, you'll work closely with the UHMAP Medical Director and play a vital part...policy that's grounded in the latest scientific research and Medicare guidelines. Your work will directly support our Health… more
- Molina Healthcare (Tampa, FL)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care....experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Dignity Health (Bakersfield, CA)
- …to the Medical Director of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related ... offices primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… more
- Molina Healthcare (Fort Worth, TX)
- …corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews… 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
- Sanford Health (Sioux Falls, SD)
- …Shifts **Job Schedule:** Full time **Weekly Hours:** 40.00 **Job Summary** The Director of Provider Network Contracting is responsible for maintaining and growing a ... resources to ensure compliance with applicable state/federal access requirements. The Director will negotiate reimbursement terms that are built on Sanford Health… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… 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
- State of Colorado (Pueblo, CO)
- …safe, secure, and therapeutic setting for patients with both psychiatric and medical issues. The services provided include evaluation and treatment for patients who ... is rendered according to the State Board of Nursing (SBON), Centers for Medicare Services (CMS), The Joint Commission (TJC), Colorado Department of Public Health and… more
- State of Colorado (Golden, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- State of Colorado (Denver, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- Peak Vista (Colorado Springs, CO)
- …programs and education. We provide integrated health care services including medical , dental, and behavioral health through our 20 outpatient health centers. ... be prorated for PT employees. Summary of Benefits: + Medical , Dental, Vision, Life, STD, LTD + 403(b) Retirement...outcomes. + Provide timely updates and reports to the Director of Population Health, QI Committee, Executive Team, and… more
- WMCHealth (Margaretville, NY)
- …+ Keep abreast of economic conditions/situations and recommend to the Activity Director adjustments in activity programs that assure the continued ability to provide ... forms, reports, etc., and submitting such to the Activity Director as required. + Committee Functions + Serve on,...before entering a resident's room. + Review complaints and grievances made by the resident and make a written/oral… more
- State of Colorado (Jefferson County, CO)
- …disabilities living in Colorado. Admissions are for individuals with complex behavior and medical needs who may pose a risk to themselves or the community. We ... individuals who have profound and severe disabilities with a high level of medical needs, and/or have significant behavioral and psychiatric challenges. The focus of… more
- Cedars-Sinai (CA)
- …Express) no later than date of discharge. + Communicates regularly with CSMPN Medical Director , Employee Health Services, Risk Management, and TPA + Attends ... 19 years in a row for providing the highest-quality medical care in Los Angeles. We were also awarded...Investigates, processes and assists with the resolution of provider grievances and appeals in accordance with contractual requirements and… more
- Atlantic Health System (Morristown, NJ)
- …athletes, coaches, and medical staff as indicated 9. Manages and resolves complex grievances related to the medical care provided to athletes 10. Acts as ... AHS affiliated School or Team Organization to autonomously provide medical care to all athletes affiliated with designated School...highest - twelve consecutive times, and the Centers for Medicare and Medicaid Services awarded us again with its… more
