- Mindlance (Syracuse, NY)
- …expeditiously to all members May be required to attend Fair Hearings with Medical Director relating to specific cases. Attends departmental meetings, as ... multiple areas, including but not limited to UM and CM, Fair Hearings and Appeals / Grievances , within three months of working in position. Demonstrates ability to… more
- Point32Health (Canton, MA)
- …(https://youtu.be/S5I\_HgoecJQ) . **Job Summary** Under the general direction of the VP, the Appeals and Grievances Director is responsible for management ... and oversight of the Enterprise Member Appeals and Grievances Department. The ...Marketing, Network Contracting, Legal, Servicing, Claims, Corporate Communications, and Medical Policy. The Director leads staff (managers… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances ... net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for… more
- LA Care Health Plan (Los Angeles, CA)
- …on medical necessity reviews. Prepares authorizations, after approval by the Medical Director . Perform other duties as assigned. Duties Continued Education ... Utilization Management/ Appeals and Grievances Nurse Specialist RN...makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the...staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in… more
- Elevance Health (Costa Mesa, CA)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... reviews of member and provider grievances and appeals . Reviews prospective or retrospective medical records...for medical necessity. + Extrapolates and summarizes medical information for medical director ,… more
- Elevance Health (Woodland Hills, CA)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... for medical necessity. + Extrapolates and summarizes medical information for medical director ,...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- The Cigna Group (Nashville, TN)
- …well as research and provide a written detailed clinical summary for the Plan Medical Director . + Determine whether additional pre service, appeal or grievance ... will include requests for decisions regarding denials of medical services as well as Part B drugs. The...C + Ability to differentiate different types of requests Appeals , Grievances , coverage determination and Organization Determinations… more
- Universal Health Services (Reno, NV)
- …Driver's license and dependable transportation required. + Excellent working relationship with Medical Management staff, Medical Director and Claims Managers ... review, research, processing and responding to written member and provider complaints, appeals , and grievances . This position is required to apply analytical… more
- Pacific Medical Centers (Seattle, WA)
- …appeals for presentation. Decision maker for all post service, network and benefit appeals . Acts as second level manager for grievances . Works with patients ... **Description** **Overview:** The operations director provides leadership for USFHP operations: including claims,...presentation. Decision maker for all post-services, network and benefit appeals . Acts as second-level manager for grievances .… more
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... ongoing relationships with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- CVS Health (Columbus, OH)
- …resistant illnesses through peer review and educational interventions.* Work with medical director teams focusing on inpatient care management, clinical ... coverage review, member appeals clinical review, medical claim review, and...the investigation of potential quality of care concerns and/or grievances * Actively support compliance functions to maintain standardized systems,… more
- Molina Healthcare (Long Beach, CA)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- UPMC (Moosic, PA)
- We have an exciting opportunity for a full-time Senior Medical Director to join our leadership team with UPMC Community Care! As Senior Medical Director , ... you to learn more and apply today! The Senior Medical Director provides guidance for clinical operational...with the Counties and DHS + Reviews complaints and grievances in accordance with Community Care procedures and ensures… more
- Molina Healthcare (Albuquerque, NM)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- AdventHealth (Maitland, FL)
- …Site position** **The role you'll contribute:** As the physician advisor, the Executive Medical Director of Revenue Cycle educates, informs, and advises members ... related to denial prevention measures for our contracted managed care payers. The Medical Director is responsible for providing physician review of utilization,… more
- Gwinnett County Public Schools (Suwanee, GA)
- …sexual harassment, and requests for accommodations on the basis of a medical impairment. The Executive Director of Employee Relations and Compliance ... Executive Director of Employee Relations and Compliance - Office...provides employees direction in matters related to grievances and appeals , and provides training and… more
- The Cigna Group (Bloomfield, CT)
- …as appropriate. + Act as clinical lead on customer and provider complaints and appeals , as requested. Manage the development of corrective actions at the member and ... provider level for quality of care grievances in the region. + Coordinate with professional relations and services to resolve provider issues. + Manage the following… more
- Highmark Health (Dover, DE)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… more
- The Cigna Group (Bloomfield, CT)
- …well as research and provide a written detailed clinical summary for the Plan Medical Director . + Determine whether additional pre service, appeal or grievance ... will include requests for decisions regarding denials of medical services as well as Part B and Part...C + Ability to differentiate different types of requests Appeals , Grievances , coverage determination and Organization Determinations… more
