- TEKsystems (Houston, TX)
- …and/or health insurance + High-level customer service + QA + Utilization management + Appeals & Grievances Education/Experience: Requires a High School ... - $20/hr and up Description: + Assist in monitoring utilization of medical services to assure cost effective use...appeals from providers and pursue resolution of formal grievances from members, responds to member and provider inquiries… 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
- 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
- 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
- Humana (Columbus, OH)
- …focused on continuously improving consumer experiences **Preferred Qualifications** + Medical utilization management experience, + working with health insurance ... Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and… more
- Elevance Health (Denison, TX)
- …+ The analyst may serve as a liaison between grievances & and appeals and /or medical management , legal, and/or service operations, and other internal ... Department that reviews analyzes and processes non-complex pre-service and post-service grievances and appeals requests from customer types (ie member,… 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
- CareFirst (Baltimore, MD)
- …health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances . **Preferred Qualifications:** + Applicants with specific ... **Knowledge, Skills and Abilities (KSAs)** + Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and… 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
- Brighton Health Plan Solutions, LLC (NC)
- …and cost-appropriate DC planning. * Provides referrals to Case management , Disease Management , Appeals & Grievances , and Quality Departments as needed. * ... About The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs daily medical necessity reviews… more
- Hackensack Meridian Health (Hackensack, NJ)
- …standards, and regulatory/payor requirements. The role integrates and coordinates utilization management , care coordination, discharge planning functions and ... of positive change. Supervises assigned staff to ensure that all case management processes are in order; including coordinating patient activities to ensure that… 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
- The Cigna Group (Bloomfield, CT)
- …**Job Requirements include, but not limited to:** + 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
- 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
- State of Colorado (Denver, CO)
- …employment laws; records management ; recruitment; retention; selection and selection appeals : responding to grievances , appeals , charges of ... Learning Management Systems Lead - Administrator IV Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/4508775) Apply Learning Management … more
- State of Colorado (Pueblo, CO)
- …subordinate staff to include coaching, mentoring, daily monitoring, performance management (planning, reviewing and evaluating), resolving complaints/ grievances ... subordinate staff to include coaching, mentoring, daily monitoring, performance management (planning, reviewing and evaluating), resolving complaints/ grievances … more
- Molina Healthcare (Long Beach, CA)
- … 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
- Molina Healthcare (Long Beach, CA)
- … 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
- State of Colorado (Lakewood, CO)
- …state personnel rules, state and federal employment laws, progressive discipline, records management , recruitment, responding to grievances , appeals , charges ... building a more equitable workplace. CDPS is an equal opportunity employer. See ourEEOD Utilization Report (2020)Why Do I Love My Job at CDPS At CDPS we nurture… more