• Manager, Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    …etc. Collaborates with internal departments (Member Services, Provider Network Operations, Claims , Utilization Management, Pharmacy, and Quality Management) to ... and State Fair Hearing files for compliance with Policies and Procedures and directives. Review and monitor procedures for identifying quality of care issues and… more
    LA Care Health Plan (03/15/24)
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  • Appeals Specialist II (Remote)

    CareFirst (Baltimore, MD)
    …and claims to assist medical professional staff in performing the review of appeals and reconsiderations. Prioritize, research, analyze, and perform accurate ... **Resp & Qualifications** **PURPOSE:** We are looking for an experienced Appeals Specialist in Baltimore, MD or surrounding counties who is willing and able to work… more
    CareFirst (03/28/24)
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  • Supervisor, Customer Solution Center…

    LA Care Health Plan (Los Angeles, CA)
    …Experience Required: At least 3-5 years in a healthcare setting in Grievances and Appeals , Compliance, Claims or Call Center. At least 2-3 years lead/supervisory ... Mission: LA Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and...Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims . Skills Required:… more
    LA Care Health Plan (01/02/24)
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  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    …and provider complaint and appeals issues, including eligibility, access to care, claims , benefit, and quality of care concerns. Experience working with firm ... This position reviews pre-service authorizations, concurrent and post-service (retroactive review ) medical necessity; benefit coverage appeals and… more
    LA Care Health Plan (02/09/24)
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  • Appeals and Grievance Analyst

    Point32Health (Canton, MA)
    …skills in all interactions. This individual prepares cases for presentation, discussion, review and final disposition at the Member Appeals Committee (MAC) ... our communities. At Point32Health, we are building on the quality , nonprofit heritage of our founding organizations, Tufts Health...**Job Summary** Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals more
    Point32Health (02/29/24)
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  • Registered Nurse (RN) - PFS Appeals

    University of Virginia (Charlottesville, VA)
    …or appeals are communicated to insurance carriers via telephonic/fax/on-line review in an organized and timely fashion. Timely follow-up with insurance carriers ... procedures is required. + Utilizes clinical knowledge, payor contracts, medical review policies, supporting research, and any other relevant documentation to… more
    University of Virginia (03/22/24)
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  • Coding Ops Education and Appeals Consultant…

    HCA Healthcare (Nashville, TN)
    …and delivery of all coding operations education components and an effective coding appeals review process for the HCA Physician Services Group (PSG). The ... Manager, provides coder specific education and global coding education based on the quality monitoring review findings and trends. This individual is a… more
    HCA Healthcare (02/17/24)
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  • Appeals Associate

    Robert Half Legal (Durham, NC)
    Description Job Title: Appeals and Grievances Specialist Location: Durham, NC 27707 - On-Site Description: As an Appeals and Grievances Specialist, you will be ... for researching and investigating all aspects of member and provider appeals , grievances, NCDOI Congressional and/or Department of Justice complaints to ensure… more
    Robert Half Legal (03/15/24)
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  • Attorney-Adviser(Veterans)

    Board of Veterans Appeals (IN)
    …and Code of Federal Regulations; the precedent decisions of the United States Court of Appeals for Veterans Claims (CAVC), the United States Court of Appeals ... skills, time management/organizational skills, knowledge of the law, efficient claims file/evidence review , and Veteran-centric decision writing. Assists… more
    Board of Veterans Appeals (03/21/24)
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  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    Customer Solution Center Appeals and Grievances Training Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, ... Mission: LA Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and...achieve that purpose. Job Summary The Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is primarily… more
    LA Care Health Plan (03/23/24)
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  • Clinical Appeals Team Lead Nurse

    HCA Healthcare (Nashville, TN)
    …satisfaction and personal growth, we encourage you to apply for our Clinical Appeals Team Lead Nurse opening. We promptly review all applications. Highly ... and integrity. We care like family! Jump-start your career as a Clinical Appeals Team Lead Nurse today with Parallon. **Benefits** Parallon, offers a total rewards… more
    HCA Healthcare (03/09/24)
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  • Claims Research & Recovery Specialist

    WelbeHealth (CA)
    …second level disputes and appeals + Coordinate the receipt, tracking, and review , of invoices related to claims or services provided to participants **Job ... and Recovery Specialist will be accountable for second level provider disputes, the review and resolution of claims related issues, and performing comparable… more
    WelbeHealth (03/22/24)
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  • Claims Quality Auditor

    UCLA Health (Los Angeles, CA)
    …to the next level. You can do all this and more at UCLA Health. The Claims Quality Auditor will be responsible for the daily audit of all examiners assigned ... to the auditor. You will review claims (paid, pending, and denied) for...and procedures. You will: * Research over and under-payment inquiries/ appeals * Compile and maintain statistical data consistent *… more
    UCLA Health (01/16/24)
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  • Senior Claims Research & Resolution…

    Humana (Indianapolis, IN)
    …decisions which may include interpretation of provider information or data. The claims review professional works in collaboration with the chief information ... for annual and quarterly State reporting of grievance and appeals . + **Workstyle:** Hybrid Office, required to work at...three days per week.** + 3+ years of medical claims review experience. + Advanced knowledge of… more
    Humana (03/19/24)
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  • Claims Processor

    Highmark Health (Sacramento, CA)
    …evaluating online entry, correcting errors and/or performing quality control review and final adjudication of paper/electronic claims . Determines whether to ... + Knowledge of operating systems specific to claim processing. + Ability to review claims and analyze critical data. + Reading benefits, investigating edits… more
    Highmark Health (03/27/24)
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  • Claims Compliance Data Validation Analyst…

    LA Care Health Plan (Los Angeles, CA)
    …internal review of proposed legislation impacting the adjudication of claims , (3) and collaborates/participates in all aspects of compliance impacting the ... Claims Compliance Data Validation Analyst II Job Category:...Mission: LA Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and… more
    LA Care Health Plan (03/21/24)
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  • Supervisory Workers' Compensation Claims

    Office of Workers' Compensation Programs (IN)
    …hearing record (transcript) and the resulting hearing decisions of the Hearings and Review claims examiners and hearing representatives in cases in which oral ... administration of the appeals processed by the Branch of Hearings and Review to include Oral Hearings and Reviews of the Written Record. Performs comprehensive… more
    Office of Workers' Compensation Programs (03/15/24)
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  • Claims Specialist I (Full-time/Billings)

    Billings Clinic (Billings, MT)
    …coordination of refunds, if appropriate, and coordinating adjustments when necessary, claims appeals or resubmissions, moving balances from insurance ... agencies by reviewing errors and other prebilling insurance reports/worklists. Analyzes and review claims to ensure that payer specific regulations and… more
    Billings Clinic (03/13/24)
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  • Acute Patient Financial Services Claims

    Banner Health (AZ)
    …responsibility balance is billed to the patient. These functions are accomplished by: + Review of Initial claims to ensure clean claim submission + Review ... **Banner Health currently has openings for Patient Financial Services** ** Claims ** **Representatives.** The Patient Financial Services (PFS) department includes: +… more
    Banner Health (03/28/24)
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  • Insurance and Claims Specialist PACE…

    HCA Healthcare (Asheville, NC)
    …position is responsible for ensuring timely and accurate processing and payment of claims by the Third-Party Administrator through competent review of claims ... that we continue to provide all patients with high quality , efficient care. Did you get into our industry...works with contracted, new, and potential network vendors regarding claims processing and payment concerns and appeals more
    HCA Healthcare (02/22/24)
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