- 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
- CareFirst (Baltimore, MD)
- …distribution and dissemination of medical policies in support of corporate philosophy, provider and member contracts, and accepted standards of medical practice. ... of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead… more
- Humana (Columbus, OH)
- … Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services… 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
- Actalent (Dayton, OH)
- … appeals and state hearings from all states * Review and complete all provider clinical appeals within required timeframes. * Review and complete member ... We are hiring for a Clinical Appeals Nurse (RN). This is a fully remote...director . * Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates. * Conduct… more
- Actalent (Dayton, OH)
- … appeals and state hearings from all states * Review and complete all provider clinical appeals within required timeframes. * Review and complete member ... We are currently hiring for a Clinical Appeals Nurse in a fully REMOTE role! A...director . * Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates. * Conduct… 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
- Elevance Health (Costa Mesa, CA)
- …may include, but are not limited to:** + 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 (Los Angeles, 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 license… more
- Elevance Health (Brentwood, TN)
- …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 license… 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
- Elevance Health (Woburn, MA)
- …or outside consultant. + Triages clinical and non-clinical inquiries, grievances and appeals , prepares case files for member grievance committees/hearings. + ... **Grievance/ Appeals Representative II** **Location:** Hybrid 500 Unicorn Park...presents essential information for the clinical specialist or medical director and legal counsel. **Minimum Requirements:** + Requires a… more
- Pacific Medical Centers (Seattle, WA)
- **Description** **Overview:** The director provides leadership for USFHP clinical operations: including care management and the clinical quality management program. ... In collaboration with the Executive Director , develops and implements policies and procedures, staff training materials, and process protocols. Oversight for… 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
- Highmark Health (Charleston, WV)
- …resources. The MHT Member Advocate must collaborate with the Care Management Director and care coordinators, provide member support related to ... Provide input to HHO management on how provider network changes will affect member access...the member as assigned. + Collaborate with Appeals & Grievances, Clinical Services, and Provider … 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