- 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
- Humana (Atlanta, GA)
- …a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews preauthorization requests ... for services. The Medical Director work assignments involve moderately complex...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … more
- Actalent (New York, NY)
- …prescribed NCQA timeframes and appeals turnaround database. + Assist the Medical Director with revising, updating, and/or creating new policies to satisfy ... Job Title: Medical Necessity Appeals and Denials FacilitatorJob...denied claims, uphold denials, and submit cases to the Medical Director for review. + Prepare case… more
- WMCHealth (Valhalla, NY)
- …the monies lost to insurance companies due to denials. Generate appropriate appeals , both retrospective and concurrent, based on medical necessity criteria. ... Denials and Appeals Mngmt Cord Company: WMC Advanced Physician Services...change from time to time. + Review and identify medical necessity denials appropriate for appeal. + Appeal appropriate… more
- CVS Health (Sacramento, CA)
- …of covered benefits in the Commercial and Medicare environment with a focus Medicare policy., This Medical Director provides subject matter expertise in ... CVS Health company, has an outstanding opportunity for a Medical Director . Ready to take your career...of Aetna clinical and coding policy and experience with appeals , claim review, reimbursement issues, and coding is preferable,… more
- Elevance Health (Tampa, FL)
- ** Medical Director - Florida Medicare ...the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... must reside in Florida near our Miami or Tampa locations.** The ** Medical Director ** will support the following Florida Medicare plans: Simply Healthcare… more
- Centene Corporation (Jefferson City, MO)
- …including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical ... with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including… 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
- CenterWell (Boston, MA)
- **Become a part of our caring community and help us put health first** The Medical Director , Primary Care relies on medical background and reviews health ... claims. The Medical Director , Primary Care work assignments involve moderately complex to...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … more
- Humana (Lansing, MI)
- **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 (Springfield, 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...individual client requested coverage determinations or appeals when appropriate. - Medical Directors will… more
- CVS Health (Des Moines, IA)
- …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
- Humana (Indianapolis, IN)
- **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
- 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 ... 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
- Centene Corporation (Salem, OR)
- …including a fresh perspective on workplace flexibility. **We're Hiring: Full time Medical Director for Trillium Community Health Plan, our Oregon market. ... knowledge of quality accreditation standards highly preferred **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical … more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and...coverage review, member appeals clinical review, medical claim review, and… more
- Evolent (Nashville, TN)
- …the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Field Medical Director you will be a key member of the utilization management team. ... on-going training per inter-rater reliability process. + May assist the Senior Medical Director in research activities/questions related to the Utilization… more
- Evolent (Oklahoma City, OK)
- …in a non-clinical setting? Join our Utilization Management team as a Field Medical Director , Cardiovascular Specialist and use your expertise in interventional ... on-going training per inter-rater reliability process. + May assist the Senior Medical Director in research activities/questions related to the Utilization… more