- 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 ... scope and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the… more
- AmeriHealth Caritas (Newark, DE)
- …for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates + Provide support ... more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the… 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)
- …productivity and quality for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case ... + Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization… 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 ... able to choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician… more
- Elevance Health (Tampa, FL)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... for medical necessity. + Extrapolates and summarizes medical information for medical director ,...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… 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 ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… 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...teams + Strong background in quality improvement, utilization management, appeals and grievances , and clinical operations +… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... coverage review, member appeals clinical review, medical claim review, and...the investigation of potential quality of care concerns and/or grievances . * Actively support compliance functions to maintain standardized… more
- Molina Healthcare (Layton, UT)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Sharp HealthCare (San Diego, CA)
- …as a physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical ... **Shift End Time** California Physicians and Surgeons License - Medical Board of CA; Doctor of Medicine (MD) **Hours**...+ Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- AdventHealth (Altamonte Springs, FL)
- …drafting and submitting clinical denial appeals , as needed + Develops Medical Director relationships with payors to have open communication and consistently ... as a liaison between UM and CM teams and medical staff, as well as, the medical ...recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in… more
- UPMC (Pittsburgh, PA)
- Purpose: The UPMC Health Plan is seeking a Medical Director that will be responsible for assuring physician commitment and delivery of comprehensive high quality ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
- Somatus (Mclean, VA)
- …the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional ... physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for… 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
- Highmark Health (St. Paul, MN)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… 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 ... Services is seeking an Assistant Dean of Students and Director of Disability Access Services. This is a full-time...meet the needs of employees and their families including: * Medical , Dental, Vision and Basic Life. OSU pays 95%… 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 ... assigning all incoming appeals and grievances...* Identifying the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver… more
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