- Point32Health (Canton, MA)
- … is responsible for management and oversight of the Enterprise Member Appeals and Grievances Department. The Director is responsible for all aspects of ... the member appeals and grievance processes for all lines of business...**Responsibilities/Duties** **- what you will be doing** + The Director is responsible for leading the Appeals … more
- The Cigna Group (Nashville, TN)
- …Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials ... **Cigna Medicare Part C Appeals Reviewer: Appeals Processing Analyst** We...Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with… more
- Universal Health Services (Reno, NV)
- …Management staff, Medical Director and Claims Managers as it relates to Member or Provider Appeals /Correspondence. + Ability to satisfactorily complete a ... ensuring the appropriate review, research, processing and responding to written member and provider complaints, appeals , and grievances. This position is… more
- Elevance Health (Palo Alto, CA)
- …providers. **How you will make an impact:** + Conducts investigations and reviews of member and provider medical necessity appeals . + Reviews prospective, ... either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals ...or any combination of education and experience, which would provide an equivalent background. + Current active unrestricted RN… more
- Elevance Health (Costa Mesa, CA)
- …may include, but are not limited to:** + Conducts investigations and reviews of member and provider grievances and appeals . Reviews prospective or ... for investigating and processing the most complex grievances and appeals requests from members and providers and provide...either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals … more
- LA Care Health Plan (Los Angeles, CA)
- …required by clinical staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in meeting regulatory timelines by ... Duties Provide non-clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This… more
- LA Care Health Plan (Los Angeles, CA)
- …area within the department. Investigation, and resolution of clinical member complaints (grievances/ appeals ) utilizing all regulatory requirements. ... Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/ appeals ) utilizing regulatory and internal… more
- Centene Corporation (Tallahassee, FL)
- …clinical information received + Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA ... for overturned denial decisions + Request additional information, as appropriate from provider (s) to facilitate timely appeals resolution + Gather and prepare… more
- Elevance Health (Woburn, MA)
- …or outside consultant. + Triages clinical and non-clinical inquiries, grievances and appeals , prepares case files for member grievance committees/hearings. + ... a check, or ask you for payment as part of consideration for employment. **Grievance/ Appeals Representative II** + Job Family: CLM > Claims Support + Type: Full time… 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 Location: Los ... public agency created by the state of California to provide health coverage to low-income Los Angeles County residents....achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is… more
- Pacific Medical Centers (Seattle, WA)
- … director provides leadership for USFHP operations: including claims, member services, enrollment, reporting/analytics and marketing. In collaboration with the ... Executive Director , develops and implements policies and procedures, staff training...requirements. Responsible for operational budget monitoring. Directly responsible for member satisfaction and develops and implements programs to improve… more
- Highmark Health (Charleston, WV)
- …or as otherwise appropriate to ensure delivery of quality and cost-effective care, member / provider satisfaction, and quality outcomes. A key component of this ... effectively. + Review utilization management cases and communicate the decisions to the member and provider . + Collaborate with Highmark Wholecare staff and… more
- Equal Employment Opportunity Commission (Washington, DC)
- … of Appellate Review Programs (ARP) manages the EEOC's national federal sector appeals program. The Associate Director position is designated as SES, General. ... at Agency and external meetings and speaks for the Director and the Commission on federal administrative appeals...basic requirement for entry into the SES, you must provide evidence of progressively responsible leadership experience that is… more
- City and County of San Francisco (San Francisco, CA)
- …service examination process is subject to change after adoption (eg, as a result of appeals ), as directed by the Human Resources Director or the Civil Service ... per day, 365 days per year. Our Mission: To provide our customers with high quality, efficient, and reliable...item(s) constitute(s) abuse of discretion by the Human Resources Director . Appeals must be submitted directly to… more
- Providence (Seattle, WA)
- **Description** **THE ROLE** The Senior Director Utilization Management & Denials - Administration is 100% remote. The role requires a broad knowledge and focus on ... the quality and cost effectives of healthcare delivery. Responsible to provide oversight and comprehensive strategic alignment, design, optimization, and improvement… more
- CVS Health (Columbus, OH)
- … teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals ... UM and participate in UM front line work and appeals as needed in OH and other markets as...(grievance) issues* Actively participate in or lead quality and/or member / provider service-focused committees* Provide clinical… more
- Humana (Columbus, OH)
- …aiding in case review, peer to peer and appeals as needed. + Provide weekend and holiday Medical Director coverage in collaboration with other market Medical ... 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 … more
- CVS Health (Harrisburg, PA)
- …such as HEDIS, Credentialing, Grievance and Appeals , SIU, etc. Coordinates provider status information with member services and other internal departments. ... + Knowledge of Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards +… more
- University of Rochester (Rochester, NY)
- Responsibilities **OVERVIEW:** The Director of Advancement will develop and manage a portfolio of principal, major gift, and leadership annual giving prospects. The ... Director will develop sufficient knowledge of Eastman to effectively...school at local, regional, and national events and to provide guidance and assistance to regional University officers representing… more
- Montana State University (Bozeman, MT)
- …for large donor cultivation, and directs or supports campaigns and appeals . The Director is a critical member of the museum's leadership team and will need ... donor base. + Develop and implement annual and special appeals as needed, and under the leadership of the...Meeting. + Ensure that the museum fulfills its many member benefits. + Support the Executive Director … more