- Humana (Topeka, KS)
- …Director (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 appropriateness and… more
- Humana (Honolulu, HI)
- … 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
- Elevance Health (Tampa, FL)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
- AmeriHealth Caritas (Newark, DE)
- …more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the ... complaints/issues to management + Monitors to ensure that all problems with appeals / grievances presented by plan members/participants are resolved in accordance… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Administrative, HR, Business Professionals Department: CSC ... Appeals & Grievances Location: Los Angeles, CA,...This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I(Temp) Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los ... 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
- Healthfirst (NY)
- …+ Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization ... quality for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case summary, contract… more
- UPMC (Pittsburgh, PA)
- …or Emergency Medicine Physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This role is ... choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician commitment and… more
- Molina Healthcare (Scottsdale, AZ)
- …and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and quality functions. You ... entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & Resolution you set the...Workflow Integration - Embed CTM insights into downstream operations-Stars, appeals & grievances , enrollment, claims-so each team… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp...trends in grievances . Supervises the process for identifying Potential Quality Issues.… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …clinical teams + Strong background in quality improvement, utilization management, appeals and grievances , and clinical operations + Insurance industry ... leader to join our team as Lead Medical Review Director -a pivotal role with a clear path toward Chief...scale\.** **What You'll Do:** + Lead medical necessity reviews, appeals , and peer\-to\-peer consultations + Supervise and mentor a… 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
- Somatus (Mclean, VA)
- …physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for ... of business including Commercial, Medicaid, Medicare, and Special Need Plans (SNPs). The Director , Quality will work closely with Sr. Manager, Audit Risk and the… more
- Molina Healthcare (Layton, UT)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Sharp HealthCare (San Diego, CA)
- …policy as needed. + Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify trends ... a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical...in grievances . Supervises the process for identifying Potential Quality Issues.… more
- City of New York (New York, NY)
- …and administer the contractual grievance process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before ... planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy… more
- AdventHealth (Altamonte Springs, FL)
- …and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting ... clinical denial appeals , as needed + Develops Medical Director relationships with payors to have open communication and consistently meets with these individuals… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …inpatient/concurrent reviews, outpatient, and retrospective reviews, Physician reviews and Appeals and Grievances processing. Primary Responsibilities + ... About The Role The Director , Utilization Management (UM) will manage the Utilization...of Clinicians and Non-Clinical support staff from Intake through Appeals processing. The ideal candidate will have a strong… more
- Oregon State University (Corvallis, OR)
- …Administrator 2-Contr & Compl Job Title Assistant Dean of Students and Director of Disability Access Services Appointment Type Professional Faculty Job Location ... Summary Disability Access Services is seeking an Assistant Dean of Students and Director of Disability Access Services. This is a full-time (1.00 FTE ), 12-month,… more
- University of Miami (Coral Gables, FL)
- …review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . The Director , Faculty Affairs supports the Vice Provost for ... and leading process improvement initiatives for the OFA. The Director engages with the Vice Provost for Faculty Affairs,...Assists the Vice Provost in managing salary review and appeals . + Reviews and process Coral Gables and Rosenstiel… more