- Humana (Topeka, KS)
- …a part of our caring community and help us put health first** The Corporate Medical Director (CMD) relies on medical background to review health claims ... and preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate… more
- Humana (Honolulu, HI)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims and ... preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… 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 Angeles, ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center Appeals & Grievance… 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
- 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
- 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...for Medicare Advantage and Dual Eligible populations, lead multidisciplinary teams,… 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 ... Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care....experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Pine Acres Rehabilitation & Care Center (Nebraska City, NE)
- …Services Director will assist residents in voicing and obtaining resolution to grievances . The Director will review complaints and grievances made by ... SOCIAL SERVICES/ADMISSIONS DIRECTOR JOB DESCRIPTION Department Social Services Reports to...actions and interactions are adequately documented in each resident's medical record, and that legal, ethical, and professional standards… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… 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 ... the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more
- State of Colorado (Pueblo, CO)
- …the Home and Community Based Services Final Rule. Counsels individuals on behavior and medical care needs during group or one on one interactions per ID team ... outlined by the Pueblo Regional Center. Addresses all complaints and resolving individual grievances at the home level. When a resident is placed in an… more
- Humana (Springfield, IL)
- …Works closely with other managers (especially the Quality Manager, Utilization Manager, and Medical Director ) and departments to address and resolve member ... provider referrals, self-referral services, preventive and enhanced services, and member grievances and appeals procedures + In close coordination with other key… more
- Saint Francis Health System (Tulsa, OK)
- …experience. Warehouse, shipping and receiving or materials management experience with medical field knowledge. Knowledge, Skills and Abilities: Knowledge of ... Medicare , TJC, federal and state regulations. Demonstrated effective management...of subordinates. Maintains positive relationships among workers and resolves grievances . Prepares composite reports from individual reports of subordinates.… more
- Dana-Farber Cancer Institute (Boston, MA)
- …concerns and requests in a compassionate, supportive manner. Reporting to the Director of Patient/Family Relations, the Patient / Family Relations (P/FR) Specialist ... and we work with amazing partners, including other Harvard Medical School-affiliated hospitals. Complaint/Grievance Management + Leads the coordination of… more
- Molina Healthcare (Orem, UT)
- …Tighter knit proximity ongoing after contract. * In conjunction with Director /Manager, Provider Contracts, negotiates Complex Provider contracts including but not ... software. * Targets and recruits additional providers to reduce member access grievances . * Engages targeted contracted providers in renegotiation of rates and/or… more
- St Croix Hospice (Mendota Heights, MN)
- …the volunteer program in in compliance with agency policy and procedure. Meets Medicare and NHPCOs standards for compliance and agency goals. + Maintains and follows ... and family/caregiver and entire hospice team. + Reports all grievances / complaints made by patients and families to...complaints made by patients and families to the Regional Director of Clinical Operations and assists with follow up.… more
- Loretto Management Corporation (Syracuse, NY)
- …and procedures, and third party agency regulations. + Applies knowledge of various Medicare , Medicaid, and other third party billing rules. + Keeps current knowledge ... personnel, including performance management, scheduling, and orientation. With the Director and Human Resources guidance, makes or approves recommendations on… more
- WellSpan Health (Mount Gretna, PA)
- …on patient's clinical presentation. + In conjunction with the Director /Manager, identifies lean management opportunities, implements process improvements and ... customer services to patients, families and personnel by assessing complaints or grievances and appropriately documenting follow up. + Promotes the personal and… more
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