- CHRISTUS Health (Alamogordo, NM)
- …automated InterQual(R) preferred. Knowledge of the regulatory environment, including Medicare Conditions of Participation, DNV standards, HIPAA, and reporting ... requirements. Submits appeals in a timely manner, upon request by the Director . Initiates discharge planning on assigned patients within 24 hours of admission.… more
- CVS Health (Hartford, CT)
- …in the US.**Responsibilities of this Medical Director role are related to Medicare Appeals .* Direct daily work on part C appeals (both provider and ... 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.* Health… more
- CareFirst (Baltimore, MD)
- …Strategic Plan through direction of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs ... needs and work activities/deliverables that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical… more
- Martin's Point Health Care (Portland, ME)
- …on clinical member and provider appeals for review by clinical team, including medical director . + Prepares and sends appeal case files for all appeal levels ... manner. The Specialist communicates and collaborates with Case Managers, Medical Directors and Compliance partners, as well as other...Health Plan benefits, particularly as it relates to Member Appeals + Cross-trains with Medicare Appeals… more
- Fallon Health (Worcester, MA)
- …according to internal measures/targets. + Present appeals to the Fallon Health Medical Director (s) as appropriate. + Serve as the liaison between the ... to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)-… more
- Elevance Health (Richmond, VA)
- …office locations Work schedule: Monday - Friday, standard business hours.** The Medical Director Clinical Programs is responsible for designing and implementing ... of Elevance Health's family of brands, offering Medicaid and Medicare plans in several states. We also provide administrative...clinical programs with specific medical condition focus for all lines of business enterprise… more
- Elderwood (Buffalo, NY)
- …a full time Medical Billing Specialist to join our team. Medical Billing Specialist ( Medicare /Managed Care) Position Overview: + Elderwood Administrative ... any denials and assist in follow up of timely appeals process. + Conduct weekly aging reviews to address...Insurance, Medical , Dental, and Vision insurance Responsibilities Medical Billing Specialist ( Medicare /Managed Care): + Review… more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Fortune 4 company, has an outstanding opportunity for a Medical Director - Medical Affairs....medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs… more
- Humana (Columbus, OH)
- **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
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the evaluation and resolution of...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- Humana (Columbus, OH)
- **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
- Humana (Columbus, OH)
- **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
- CVS Health (Columbus, OH)
- …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) Experience with managed care ( Medicare… more
- LA Care Health Plan (Los Angeles, CA)
- Medical Director , Medical Management Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time ... net required to achieve that purpose. Job Summary The Medical Director , Medical Management, is...of care, complex care rounds, interdisciplinary care team rounds, appeals and grievances and provider disputes. On day to… more
- Elevance Health (Denver, CO)
- … reviews within our Medicaid and Medicare programs.** The **Behavioral Health Medical Director ** is responsible for the administration of behavioral health ... of Elevance Health's family of brands, offering Medicaid and Medicare plans in several states. We also provide administrative...opportunities. May serve as a resource to staff including Medical Director Associates. How you will make… more
- Centers Plan for Healthy Living (Staten Island, NY)
- …and HHCAHPS sites to obtain quality data. + Oversight of Medicare Expedited appeals and conventional Medicare appeals process. Maintains records of all ... Director Quality Management/Compliance Officer 75 Vanderbilt Ave, Staten...appeals . Serves as the Agency's contact with the Medicare QIO. + Oversight of risk management, including documentation… more
- Lancaster General Health (Lancaster, PA)
- **Summary** **Job Description** **POSITION SUMMARY:** The Associate Medical Director , Hospitalist Services is responsible for assisting the Medical ... The Associate director will report to LGHP Medical Director and have a reporting relationship...their satisfaction with LRH's services + Provide assistance with appeals of claims denied by government and other third-party… more
- Humana (Tallahassee, FL)
- …our caring community and help us put health first** The Behavioral Health Cluster Lead Medical Director manages a team of Behavioral Health Medical Directors ... Carolina, Virginia, Louisiana or Oklahoma The Behavioral Health lead medical director will be board certified, retain...in a health plan setting, preferably with Medicaid and Medicare membership * Experience in managing other medical… more
- Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)
- …and Second Level Administrative Appeals as directed by the Senior Medical Director . + Completes required training activities in a timely manner. ... people + This role reports to this job: SENIOR MEDICAL DIRECTOR (MGR) + Necessary Contacts: department...initial and appeal and the related procedure. + Performs medical or administrative appeals as needed based… more
- AmeriHealth Caritas (Newark, DE)
- ** Medical Director , LTSS (must reside in DE)** Location: Newark, DE Primary Job Function: Medical Management ID**: 34195 **Job Brief** Qualified candidates ... and related policy and practice initiatives in collaboration with the Corporate Medical Director (s), Senior Medical Directors, Utilization Management and… more
