- CVS Health (CT)
- …in the US. **Responsibilities of this Medical Director role are related to Medicare Appeals :** * Direct daily work on part C appeals (both provider ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal...Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. *… more
- Humana (Topeka, KS)
- … (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… 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 ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Molina Healthcare (Kenosha, WI)
- …direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements ... for Medicare and Medicaid Services. * Trains grievance and appeals staff, customer/member services department, sales, UM and other departments within Molina… more
- Sanford Health (Sioux Falls, SD)
- …oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, including ACA, ... Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures...all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced level work related to clinical denial management. The ... determine if an appeal is warranted. + Formulate clinical appeals and letters of medical necessity to...trends; including denials that have been escalated to the Medicare Administrative Law Judge (ALJ). + Represent DFCI at… more
- CommonSpirit Health (Englewood, CO)
- …and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate ... are seeking a highly skilled individual to develop and submit clinical appeals , expertly crafting physician-aligned letters based on federal and state regulations,… more
- Molina Healthcare (WI)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- OhioHealth (Columbus, OH)
- …Manager with updates. CGS audits and auditors Working with our legal vendor for Medicare Appeals . Working with OHA and CBSA facilities on wage index ... matter expert in the following areas, S-10, Wage Index, Bad Debts, Medicare Audits, Disproportionate Share, Indirect Medical Education, Graduate Medical… more
- Houston Methodist (Katy, TX)
- …medical coding, insurance billing, collections, patient account resolution, appeals /denials, customer service, cash applications, revenue integrity, etc. This ... procedures, and provides quality reviews. Reports results of key performance metrics to director on a timely basis. **FINANCE ESSENTIAL FUNCTIONS** + Assists in the… more
- Humana (Montgomery, AL)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … more
- Humana (Washington, DC)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- CVS Health (IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Fortune 6 company, has an outstanding opportunity for a Medical Director ( Medical Affairs). This...individual client requested coverage determinations or appeals when appropriate. - Medical Directors will… more
- Humana (San Juan, PR)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes reviewing of all… more
- CVS Health (CT)
- …will perform concurrent and prior authorization reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals in ... services to its membership. Aetna is looking for a medical director to be part of a...Two (2) + years of experience in managed care ( Medicare and/or Medicaid) MD or DO; Board certification in… 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
- Humana (Raleigh, NC)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...group practice management. + Utilization management experience in a medical management review organization, such as Medicare … more
- Blue KC (MO)
- …financial assistance** **Employee discount program** **Job Description Summary:** The Lead Medical Director actively uses their clinical training, experience, ... and/or requested site of service should be authorized. The Medical Director will apply various clinical policies,...medical , surgical and pharmacy activity. + Participates in medical appeals activity. Reviews all appealed cases… more
- Martin's Point Health Care (Portland, ME)
- …been certified as a "Great Place to Work" since 2015. Position Summary The Medical Director (MD) provides clinical leadership and direction to the utilization & ... drive short and long-range clinical programming, quality management, and external relationships. The Medical Director reports to the Vice President Health Plan … more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... for all of Sharp Health Plan products, (Commercial, Exchange, Medicare , POS/PPO) services, and oversees the health care needs...+ 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons… more