- LA Care Health Plan (Los Angeles, CA)
- Utilization Management / Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los ... net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides… more
- Centers Plan for Healthy Living (Margate, FL)
- …in related area of responsibility, (ie utilization management , quality management , grievances , and appeals ) Type of Experience Required: Strong ... RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate,...handle expedited and standard requests and ensures that the appeals are processed in accordance with regulations, compliance standards… more
- LA Care Health Plan (Los Angeles, CA)
- …Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management , Pharmacy, and Quality Management ) to ... Manager, Customer Solution Center Appeals and Grievances Job Category: Customer...work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management , Quality Management , Pharmacy)… more
- Apex Health Solutions (Houston, TX)
- …grievances . This associate may screen incoming complaints, process medical necessity, utilization management and claims appeals , initiate Independent ... Job Title: Appeals & Grievances Coordinator Department: ...a daily basis with the Customer Service Department, Medical Management Department, Medical Directors, enrollees, providers and TPA Staff… more
- Point32Health (Canton, MA)
- …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 Director is responsible for all aspects...of management experience. Understanding of operations process, utilization management and associated regulatory and accreditation… more
- Elevance Health (Woodland Hills, CA)
- …+ The analyst may serve as a liaison between grievances & appeals and /or medical management , legal, and/or service operations and other internal ... you for payment as part of consideration for employment. ** Grievances and Appeals Analyst I** + Job...to convey the determination. + Responsibilities exclude conducting any utilization or medical management review activities which… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN...a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute for the supervisory/… more
- Elevance Health (Norfolk, VA)
- …+ The analyst may serve as a liaison between grievances & appeals and /or medical management , legal, and/or service operations and other internal ... that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (ie member, provider,… more
- Universal Health Services (Reno, NV)
- …both verbally and in writing. + Understanding of claims payment and utilization management process. + Excellent organizational, written, and oral, communication, ... review, research, processing and responding to written member and provider complaints, appeals , and grievances . This position is required to apply analytical… more
- FLACRA (Clifton Springs, NY)
- UTILIZATION MANAGEMENT SPECIALIST Finger Lakes Addiction Counseling and Referral Agency Inc Clifton Springs, NY (Onsite) Full-Time $16.00 - $17.30/Hour Apply Now ... Job Summary: In accordance with the organization's mission, vision and values, the Utilization Management Specialist is responsible for evaluation of the medical… more
- Ventura County (Ventura, CA)
- …Thorough knowledge of: mental health and substance abuse assessment, treatment, and case management practices; grievances , appeals and notices of actions; ... the state and federal governing entities, and resolves, tracks, and monitors grievances , appeals and Notices of Actions. This position continually collaborates… more
- Highmark Health (Charleston, WV)
- …standards, and practitioner/provider education. The incumbent is an integral part of the utilization management team and assists utilization management ... State of West Virginia **ESSENTIAL RESPONSIBILITIES** + Communicate effectively. + Review utilization management cases and communicate the decisions to the… more
- The Cigna Group (Nashville, TN)
- …shifts with every other weekend (Tuesday ALT Day).** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part C ... + Ability to differentiate different types of requests Appeals , Grievances , coverage determination and Organization Determinations in order to ensure the correct… more
- Molina Healthcare (Detroit, MI)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical...analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory,… more
- AdventHealth (Maitland, FL)
- …and changes related to Care Management ..Serves as a member of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and ... experience **_E_** **_XPERIENCE_** **_P_** **_REFERRED_** _:_ . Understanding of Hospital Care Management , including Utilization Management . Two years or… more
- CVS Health (Columbus, OH)
- …health outcomes* Leverage extensive knowledge of health care delivery system, utilization management , reimbursement methods and treatment protocols for DSNP/MMP ... Behavioral Health, Pharmacy, member outreach, Care Management , National Quality Management , Utilization Management , Compliance, and other departments to… more
- Centene Corporation (Tallahassee, FL)
- …Provides leadership and direction over the strategic sourcing process for all utilization management vendor services and oversees the Enterprise's Partnerships ... terms, standards and expectations are met, which includes Internal operations (Claims, Appeals & Grievances , and Membership) + Partners with Compliance to… more
- UPMC (Moosic, PA)
- …consultation with practitioners in the field. This includes significant responsibility for quality management and utilization management and for assuring the ... protocols. + Review the medical aspects of cost and utilization reports generated by Medical Management Information...processes. + Ensures prompt and fair resolution of care management decision appeals + Interfaces with physician… more
- LA Care Health Plan (Los Angeles, CA)
- Clinical Operations Executive Job Category: Management /Executive Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full ... Officer (CMO) and is responsible for operational and administrative management of the Utilization Management ...Operating Officer (COO) to allow for integration with claims, appeals and grievances , and our customer service… more
- Tiburcio Vasquez Health Center (Hayward, CA)
- …directors and reporting teams in resolving utilization issues, claims reviews, grievances , appeals , and other medical management challenges. Directs and ... Quality Department to identify, and oversee the development of quality and utilization management activities that meet the needs of TVHC providers, members, and… more