- Fallon Health (Worcester, MA)
- …on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** The Fallon Health (FH) Appeals and Grievance process is an essential function to FH compliance ... & Grievances Coordinator serves to administer the FH Appeals and Grievance process as outlined in...presentation of the member appeal to the FH Medical Director , Center for Medicare/Medicaid Services, contracted reviewer, as well… more
- CVS Health (Hartford, CT)
- …remote based (work at home) based anywhere in the US. Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part ... AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- CVS Health (Hartford, CT)
- …of this Medical Director role are related to Part C Medicare Appeals . This position is primary on the non-regulated appeals team, however the ... ABMS Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… 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
- Commonwealth Care Alliance (Boston, MA)
- …+ Prepares recommendations to either uphold or deny appeal and forwards to Medical Director as needed. + Ensures that appeals and grievances are resolved timely ... 011540 CCA- Appeals & Grievances **Position Summary:** Investigate and resolve...to meet regulatory timeframes. + Documents and logs appeal/ grievance information on relevant tracking systems. + Utilize industry… more
- Elevance Health (Mason, OH)
- …+ 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 (Dover, DE)
- …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
- Humana (Dover, DE)
- …Some roles include an overview of coding practices and clinical documentation, dispute/ grievance and appeals processes, and outpatient services and equipment, ... community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement...of care received. May also engage in disputes and 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
- 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
- CUNY (Staten Island, NY)
- …clear, concise, analytical, legally correct, accurate and persuasive briefs, appeals , motions, grievance responses and settlement agreements.Demonstrated ability ... Legal Counsel and Labor Relations Director **POSITION DETAILS** The College of Staten Island...Executive Legal Counsel, the Legal Counsel and Labor Relations Director will handle all legal matters, investigations, subpoenas, FOIL's,… more
- Elevance Health (Seattle, WA)
- …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 (Miami, FL)
- …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
- Elevance Health (Cincinnati, OH)
- Job Description **LTSS Director - Planning & Strategy Lead** **(** **Strategy & Prog Dev Dir** **ector)** **_Preferred Location: Ohio. This position is hybrid and ... health, long term services and supports, and psychosocial needs._ The **LTSS Director - Planning & Strategy Lead** is responsible for providing strategic leadership… 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 (Jacksonville, FL)
- …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
- Johns Hopkins University (Baltimore, MD)
- …Office of Employee and Labor Relations. This position will report, to the Director of Employee Relations and Labor Relations (ER/LR). This position will provide a ... actions and make sound recommendations to management. + Manage the grievance process, including fact finding, reviewing evidence, serving as hearing officer,… more
- University of Delaware (Newark, DE)
- …32E Context of the Job: Under the limited direction of the Senior Director , Employee and Labor Relations, the Employee and Labor Relations Manager, is responsible ... bargaining negotiations. Major Responsibilities: + In collaboration with the Senior Director , assists with the planning, execution, and evaluation of employee and… more