- MVP Health Care (Schenectady, NY)
- Director , Appeals and Grievances 625 State St, Schenectady, NY 12305, USA Req #2608 Friday, May 16, 2025 At MVP Health Care, we're on a mission to create a ... innovative thinking and continuous improvement. To achieve this, we're looking for a Director , Appeals & Grievances to join #TeamMVP. This is the opportunity… more
- Molina Healthcare (Spokane, WA)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving...monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and… more
- 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 (Sacramento, CA)
- … 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. + Ensure that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... + 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-clinical… more
- Healthfirst (UT)
- …+ 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
- 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
- Excellus BlueCross BlueShield (Buffalo, NY)
- …on the Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) ... care system. + Develops, conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as… more
- State of Colorado (Pueblo, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Inv Director Continuity of Treatment Office - Health Professional...plans; signs performance plans and appraisals; and resolves informal/formal grievances + Initiates and/or delegates the hiring process, interviews… more
- Molina Healthcare (Seattle, WA)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... **JOB DESCRIPTION** **Job Summary** The Medical Director for Specialty Medical Services & Market Performance will provide clinical expertise and support to the… more
- Guardian Life (Austin, TX)
- …compliant with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and ... The **Texas State Dental Director ** will be responsible for ensuring that professional...ensure that determination and processing of claims, referrals and appeals meet state regulations, time frames & definitions +… 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
- Fallon Health (Worcester, MA)
- …NCQA standards, other applicable regulatory requirements and member expectations. The FH Member Appeals & Grievances Coordinator serves to administer the FH ... of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between FH… 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
- Martin's Point Health Care (Portland, ME)
- …HP to ensure compliance with government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice + ... to Work" since 2015. Position Summary The VP Medical Director of Clinical Programs will manage the Health Plan...the Health Plan Medical Directors and, as a Medical Director team, provide clinical support for the Health Management… more
- Dairy Farmers of America (Kansas City, KS)
- …problems, such as working conditions, disciplinary actions, and employee and applicant appeals and grievances + Evaluate and assist with effective resolution ... of grievances and other local conflicts resulting from labor agreements + Develop and maintain effective relationships with union leadership to foster and… more
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The Medical Director , Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC Health… more
- Centene Corporation (Olympia, WA)
- …+ Develops, Implements and Conducts concurrent and retrospective reviews of claims and appeals , and resolves grievances related to medical quality of care. + ... perspective on workplace flexibility. **Position Purpose:** The Behavioral Health Medical Director provides clinical leadership and support of the Chief Medical… more
- Highmark Health (Des Moines, IA)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
- Molina Healthcare (Everett, WA)
- …for claims payment); Provider/Member Inquiry Research and Resolution; and Provider/Member Appeals and Grievances . * Coordinates with Corporate and Business ... Development teams to ensure that Molina grows faster (profitable growth) than our competitors in target new markets and expansion opportunities. * Provides training and guidance as needed to the Contract Managers and Contract Specialist(s). * Helps develop and… more