- Humana (Topeka, KS)
- …a part of our caring community and help us put health first** The Corporate Medical Director (CMD) relies on medical background to review health claims ... and preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate… more
- Humana (Olympia, WA)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims and ... preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… 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
- Molina Healthcare (Kenosha, WI)
- …with the standards and requirements established by the Centers for Medicare and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the ... activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized… more
- Molina Healthcare (WI)
- …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
- 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
- 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
- Pine Acres Rehabilitation & Care Center (Nebraska City, NE)
- …Services Director will assist residents in voicing and obtaining resolution to grievances . The Director will review complaints and grievances made by ... SOCIAL SERVICES/ADMISSIONS DIRECTOR JOB DESCRIPTION Department Social Services Reports to...actions and interactions are adequately documented in each resident's medical record, and that legal, ethical, and professional standards… more
- Somatus (Mclean, VA)
- …provides guidance and oversight to all lines of business including Commercial, Medicaid, Medicare , and Special Need Plans (SNPs). The Director , Quality will work ... the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional… more
- Trinity Health (Pensacola, FL)
- …The Director , Quality Improvement and Compliance, in collaboration with the Medical Director , is responsible for developing and implementing the annual QI ... implement the annual Quality Improvement (QI) Plan with the Medical Director + In conjunction with ...compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program.… more
- Molina Healthcare (San Bernardino, CA)
- …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
- 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
- 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
- State of Colorado (Denver, CO)
- …security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… 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
- AdventHealth (Wesley Chapel, FL)
- …As the RN Clinical Risk Manager, operating under the direction of the Director , assists in the planning and implementation activities of the facility-wide Risk ... control activities, and maintaining appropriate risk management records. Assists the director with quality-of-care issues by using established Policy and Procedures,… more
- Saint Francis Health System (Tulsa, OK)
- …experience. Warehouse, shipping and receiving or materials management experience with medical field knowledge. Knowledge, Skills and Abilities: Knowledge of ... Medicare , TJC, federal and state regulations. Demonstrated effective management...of subordinates. Maintains positive relationships among workers and resolves grievances . Prepares composite reports from individual reports of subordinates.… more
- Commonwealth Care Alliance (Boston, MA)
- …staff, including nurse reviewers and support personnel. * Act as liaison with medical director , provider relations, case management and quality teams to support ... Management (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care… more
- Dana-Farber Cancer Institute (Boston, MA)
- …concerns and requests in a compassionate, supportive manner. Reporting to the Director of Patient/Family Relations, the Patient / Family Relations (P/FR) Specialist ... and we work with amazing partners, including other Harvard Medical School-affiliated hospitals. Complaint/Grievance Management + Leads the coordination of… more