- CVS Health (Hartford, CT)
- …in the US. Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part C appeals (both provider and ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal...Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. *… more
- Humana (Topeka, KS)
- … (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 (Honolulu, HI)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced level work related to clinical denial management. The ... determine if an appeal is warranted. + Formulate clinical appeals and letters of medical necessity to...trends; including denials that have been escalated to the Medicare Administrative Law Judge (ALJ). + Represent DFCI at… more
- Humana (Carson City, NV)
- **Become 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 work assignments involve moderately complex to complex issues...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … 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 timelines by ... Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive… more
- Healthfirst (NY)
- …productivity and quality for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case ... of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of… more
- Houston Methodist (Katy, TX)
- …medical coding, insurance billing, collections, patient account resolution, appeals /denials, customer service, cash applications, revenue integrity, etc. This ... HB Epic AR management experience + Strong working knowledge of Facility Medicare (Part A) guidelines. + Problem solving thought leader with proven execution… more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Fortune 6 company, has an outstanding opportunity for a Medical Director ( Medical Affairs). This...individual client requested coverage determinations or appeals when appropriate. - Medical Directors will… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …clear path toward Chief Medical Officer responsibilities\.** **This is more than a medical director role\. It's an opportunity to shape the future of care ... experienced clinical leader to join our team as Lead Medical Review Director -a pivotal role with a...and performance at scale\.** **What You'll Do:** + Lead medical necessity reviews, appeals , and peer\-to\-peer consultations… more
- Humana (Baton Rouge, LA)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... to operationalize this knowledge in their daily work specifically for DSNP. The Medical Director 's work includes computer-based review of moderately complex to… more
- CVS Health (Hartford, CT)
- …will perform concurrent and prior authorization reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals in ... services to its membership. Aetna is looking for a medical director to be part of a...Two (2) + years of experience in managed care ( Medicare and/or Medicaid) MD or DO; Board certification in… more
- Humana (Raleigh, NC)
- **Become 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 work assignments involve moderately complex to complex issues...group practice management. + Utilization management experience in a medical management review organization, such as Medicare … more
- Molina Healthcare (Layton, UT)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Blue KC (MO)
- …financial assistance** **Employee discount program** **Job Description Summary:** The Lead Medical Director actively uses their clinical training, experience, ... and/or requested site of service should be authorized. The Medical Director will apply various clinical policies,...medical , surgical and pharmacy activity. + Participates in medical appeals activity. Reviews all appealed cases… more
- Martin's Point Health Care (Portland, ME)
- …been certified as a "Great Place to Work" since 2015. Position Summary The Medical Director (MD) provides clinical leadership and direction to the utilization & ... drive short and long-range clinical programming, quality management, and external relationships. The Medical Director reports to the Vice President Health Plan … more
- 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 ... for all of Sharp Health Plan products, (Commercial, Exchange, Medicare , POS/PPO) services, and oversees the health care needs...+ 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and...coverage review, member appeals clinical review, medical claim review, and… more
- Centene Corporation (New York, NY)
- …quality accreditation standards. + Actively practices medicine **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical ... implementation of performance improvement initiatives for capitated providers. + Assists Chief Medical Director in planning and establishing goals and policies… more
- Evolent (Helena, MT)
- …the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Field Medical Director you will be a key member of the utilization management team. ... on-going training per inter-rater reliability process. + May assist the Senior Medical Director in research activities/questions related to the Utilization… more