- Inland Empire Health Plan (Rancho Cucamonga, CA)
- …management, quality management, utilization management (UM), and grievance and appeals and committee participation. The Medical Director of Behavioral Health ... pivot from a "job" opportunity to an authentic experience! The Medical Director of Behavioral Health is responsible for clinical oversight, clinical leadership, and… more
- Molina Healthcare (San Antonio, TX)
- …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... dispute/ appeals processing. * Establishes member and non-contracted provider grievance /dispute and appeals policies/procedures and updates annually or as… more
- Molina Healthcare (St. Petersburg, FL)
- …Responsible for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that is responsible for reviewing and resolving ... in line with state and federal regulations. Responsible for managing the Appeals and Grievance department inventories within the key performance requirements.… 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 ... (15%) Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director , ongoing referrals and authorizations… more
- LA Care Health Plan (Los Angeles, CA)
- …consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all line of business (LOB) to identify ... This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as...the Management Team. Duties Focus on quality review of grievance and appeals cases for all LOB… more
- 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 resolved ... **Nurse Appeals - Medicare** **Location:** Virtual: This role enables...timely to meet regulatory timeframes. + Documents and logs appeal/ grievance information on relevant tracking systems and mainframe systems.… more
- Humana (Salem, OR)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors… more
- Humana (Olympia, WA)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Humana (Charleston, WV)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement...member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Sharp HealthCare (San Diego, CA)
- …and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) ... 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage review, member… more
- Sharp HealthCare (San Diego, CA)
- …physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical Board of CA ... from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains benchmarked utilization… more
- Humana (Bismarck, ND)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... 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
- Elevance Health (Costa Mesa, CA)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Associate Medical Director ** **Carelon Medical Management** **Outpatient Rehab Utilization Management** **Virtual:** This role enables… more
- Elevance Health (Atlanta, GA)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Medical Director ** **Carelon MBM** **Virtual:** This role enables associates to work virtually full-time, with the exception of required… more
- Dairy Farmers of America (Kansas City, KS)
- …negotiate contracts, interpret the collective bargaining agreements, and administer grievance procedures and arbitrations. Provide expertise and guidance on labor ... problems, such as working conditions, disciplinary actions, and employee and applicant appeals and grievances + Evaluate and assist with effective resolution of… more
- UPMC (Pittsburgh, PA)
- …a board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This role is fully ... between 8am - 4pm EST, in order to attend grievance hearings. One of the perks of this position...weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician commitment and… more
- Somatus (Mclean, VA)
- …+ Oversee new client pre-delegation audits, annual client audits, development of grievance and appeals workflow processes, and other regulatory requirements. + ... well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality,...Commercial, Medicaid, Medicare, and Special Need Plans (SNPs). The Director , Quality will work closely with Sr. Manager, Audit… more
- Molina Healthcare (Phoenix, AZ)
- …procedures regarding compliance with local, state and federal guidelines. + Establishes member grievance appeals and policies and updates annually or as directed ... for Medicare and Medicaid Services. + Establishes non-contracted provider dispute and appeals policies and policies and updates annually or as directed by the… more
- Transdev (Readville, MA)
- …The Labor Relations Manager provides support to the General Manager and Director of Human Resources on labor relations projects, priorities and issues. This ... + Research, compile, and prepare data for use in grievance hearings, arbitration proceedings, labor/management initiatives, collective bargaining negotiations, and… more
