- 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
- 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 ... each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case...(NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines + Ability to work independently… more
- Molina Healthcare (Scottsdale, AZ)
- …or related field (advanced degree a plus). **Experience** * 7+ years managing Medicare CTM, appeals & grievances , or related compliance functions-hands-on ... must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and...SLA tracking, and program audits. * Deep knowledge of Medicare regulations affecting complaints, grievances , and member… more
- Commonwealth Care Alliance (Boston, MA)
- …of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the ... schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and… 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...an opportunity to shape the future of care for Medicare Advantage and Dual Eligible populations, lead multidisciplinary teams,… 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 ... and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP)… 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
- CVS Health (Tallahassee, FL)
- …oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for ... UM and participate in UM front line work and appeals in markets as needed. * Confer directly with...peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage… more
- Somatus (Mclean, VA)
- …provides guidance and oversight to all lines of business including Commercial, Medicaid, Medicare , and Special Need Plans (SNPs). The Director , Quality will work ... physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for… more
- Fallon Health (Worcester, MA)
- …of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and ... be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for...assigning all incoming appeals and grievances… more
- Humana (Springfield, IL)
- …Manager, and Medical Director ) and departments to address and resolve member grievances and appeals . + Oversees the interface with the Enrollment Broker ... specialty provider referrals, self-referral services, preventive and enhanced services, and member grievances and appeals procedures + In close coordination with… more
- 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
Related Job Searches:
Appeals,
Appeals Grievances,
Director,
Director Appeals Grievances,
Grievances,
Medicare