• Blue Shield of California (Oakland, CA)
    … and Grievances , and provider claims dispute reviews. The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance ... accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to… more
    Upward (07/10/25)
    - Save Job - Related Jobs - Block Source
  • 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 ... quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. Facilitates conformance to… more
    Upward (06/30/25)
    - Save Job - Related Jobs - Block Source
  • Alameda Alliance For Health (Alameda, CA)
    …Representatives are under the direction of a Member Services Supervisor, Manager and Director , and service our members through our call center as well assisting ... system. Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes,… more
    Upward (07/13/25)
    - Save Job - Related Jobs - Block Source
  • COMMUNITY HEALTH GROUP (Chula Vista, CA)
    …day-to-day operations of the Corporate Quality Department including the areas of grievances and appeals (G&A), the identification, resolution, and tracking of ... potential quality issues (PQIs), facility and medical record reviews, Health Effectiveness Data and Information Set...standards of practice. Supervises the Corporate Quality Nurses, the Grievances and Appeals Supervisor, and the Corporate… more
    Upward (07/03/25)
    - Save Job - Related Jobs - Block Source
  • Medicare Grievances and Appeals

    Humana (Little Rock, AR)
    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… more
    Humana (06/18/25)
    - Save Job - Related Jobs - Block Source
  • Director , Appeals

    Molina Healthcare (St. Petersburg, FL)
    …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
    Molina Healthcare (07/20/25)
    - Save Job - Related Jobs - Block Source
  • Director , Appeals

    Molina Healthcare (San Antonio, TX)
    …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and… more
    Molina Healthcare (07/18/25)
    - Save Job - Related Jobs - Block Source
  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Accounting/Finance 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 (07/24/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director - Medicare…

    Humana (Carson City, NV)
    … (CMD) relies on medical background to review 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 regarding the… more
    Humana (07/23/25)
    - Save Job - Related Jobs - Block Source
  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    Customer Solution Center Appeals and Grievances Coordinator I (Temporary) Job Category: Customer Service Department: CSC Appeals & Grievances Location: ... 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
    LA Care Health Plan (07/22/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director , Grievances

    UPMC (Pittsburgh, PA)
    …seeking a board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This ... able to choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician… more
    UPMC (06/29/25)
    - Save Job - Related Jobs - Block Source
  • Nurse Appeals - Medicare

    Elevance Health (Tampa, FL)
    …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
    Elevance Health (07/23/25)
    - Save Job - Related Jobs - Block Source
  • Senior Medical Director - Sharp…

    Sharp HealthCare (San Diego, CA)
    …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
    Sharp HealthCare (07/19/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director , Children's…

    Excellus BlueCross BlueShield (Buffalo, NY)
    …conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as needed. + Ensures that ... of the Children's Behavioral Health (BH) Carve-In program. The Medical Director for BH Children's Services has...Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular… more
    Excellus BlueCross BlueShield (05/10/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director - Dsnp/MMP

    CVS Health (Tallahassee, FL)
    …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… more
    CVS Health (07/18/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director (CT)

    Molina Healthcare (WI)
    …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
    Molina Healthcare (07/11/25)
    - Save Job - Related Jobs - Block Source
  • Director of Education (State Teacher IV)

    State of Colorado (Pueblo, CO)
    …appeal with the State Personnel Board or request a review by the State Personnel Director . You will find the appeals process, the official appeal form, and how ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
    State of Colorado (07/25/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director - Sharp Health Plan…

    Sharp HealthCare (San Diego, CA)
    …as a physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical ... **Shift End Time** California Physicians and Surgeons License - Medical Board of CA; Doctor of Medicine (MD) **Hours**...+ Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
    Sharp HealthCare (05/18/25)
    - Save Job - Related Jobs - Block Source
  • Medical Director - Utilization…

    UPMC (Pittsburgh, PA)
    The Medical Director , Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
    UPMC (06/12/25)
    - Save Job - Related Jobs - Block Source
  • Director , Quality

    Somatus (Mclean, VA)
    …the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional ... physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for… more
    Somatus (05/13/25)
    - Save Job - Related Jobs - Block Source