- Stanford Health Care (Palo Alto, CA)
- …to effectively facilitate work groups to successful outcomes. + Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, ... the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position requires strong… more
- Stony Brook University (East Setauket, NY)
- …**Preferred:** + Experience investigating, reviewing, and following up on rejected, denied insurance claims and/or experience using claims scrubber systems. ... will support day-to-day business functions including but not limited to: billing, claims analysis appeals , follow-up, financial assistance and customer service.… more
- Rady Children's Hospital San Diego (San Diego, CA)
- …This position is responsible for pulling medical records to submit with claims and appeals as required by payors. Responsible to validate and accurately ... register new patients in the system, including patient demographics, verifying insurance , eligibility and claim information is accurate. Incumbent will verify… more
- Swedish Health Services (Seattle, WA)
- …Re-submit claims to government agencies, medical service bureaus, and insurance companies. Submit claims appeals with supporting documentation as ... **Description** Follow up on insurance denials and aged claims , submit...we must empower them. **Required Qualifications:** + 2 years medical (or healthcare) insurance follow up experience.… more
- Covenant Health Inc. (Knoxville, TN)
- Overview Insurance Appeals Senior , Revenue Integrity and Utilization Full Time, 80 Hours Per Pay Period, Day Shift Covenant Health Overview: Covenant Health is ... integrity auditor to take appropriate action. Prepares necessary documentation for insurance appeals process, ensuring timely follow through. Processes claim… more
- Mount Sinai Health System (New York, NY)
- …(Industry-Specific)** : + Healthcare: Experience with utilization management for medical services, procedures, or medications + Insurance : Understanding ... **Job Description** **Director Pre Appeals Management-HSO Appeals Management -Corporate 42nd...management program. This role ensures the appropriate use of medical resources, compliance with regulatory standards, and coordination of… more
- Point32Health (FL)
- …and Federal regulatory requirements + Manage the collection of documents and records ( medical , claims , administrative) needed to fully research the appeal or ... service or member services representative in health care or insurance + Preferred: 2 years' Appeals and...and comprehensive total rewards package which currently includes: + Medical , dental and vision coverage + Retirement plans +… more
- LA Care Health Plan (Los Angeles, CA)
- …Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance ... position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations,… more
- MTA (Brooklyn, NY)
- Assistant General Counsel III - Appeals , Torts Job ID: 12066 Business Unit: New York City Transit Location: Brooklyn, NY, United States Regular/Temporary: Regular ... Posted: Jul 10, 2025 Description Job Information Assistant General Counsel III - Appeals , Torts First Date of Posting: 7/10/2025 Last Date of Filing: Until Filled… more
- Molina Healthcare (Salt Lake City, UT)
- …to reduce the likelihood of a formal appeal being submitted. * Reevaluates medical claims and associated records independently by applying advanced clinical ... in the specific programs supported by the plan such as utilization review, medical claims review, long-term services and supports (LTSS), or other specific… more
- Elevance Health (South Portland, ME)
- …to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to ... analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or...minimum of 3 years experience working in grievances and appeals , claims , or customer service; or any… more
- Point32Health (Canton, MA)
- …and Federal regulatory requirements + Manage the collection of documents and records ( medical , claims , administrative) needed to fully research the appeal or ... **Job Summary** Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals ...and comprehensive total rewards package which currently includes: + Medical , dental and vision coverage + Retirement plans +… more
- Intermountain Health (Des Moines, IA)
- …+ Understands ERISA, self-funded and federal and state laws around health insurance claims . + Develops and maintains collaborative relations with Intermountain ... **Job Description:** The RCO Appeals Hearing Specialist is responsible for investigating, coordinating...+ Communication + Organizational skills + Computer Literacy + Medical terminology + Problem Solving + Health Insurance… more
- Actalent (New York, NY)
- Job Title: Medical Necessity Appeals and Denials FacilitatorJob Description This role involves facilitating medical necessity appeals and denials, ... claims , uphold denials, and submit cases to the Medical Director for review. + Prepare case reviews for... appeals process within prescribed NCQA timeframes and appeals turnaround database. + Assist the Medical … more
- Humana (San Juan, PR)
- …inbound call center or related customer service experience + Previous experience processing medical claims + Bilingual (English and Spanish); with the ability to ... and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by...+ **Must have experience in the healthcare industry or medical field** + Strong data entry skills required +… more
- HCA Healthcare (Nashville, TN)
- …policy requirements. + Strong ability to research evidence-based practices. + Identify problem claims and appeals and escalate as appropriate. + Update the RRT ... an organization that invests in you as a Clinical Appeals Specialist Medicare RN or LPN? At Parallon, you...colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no… more
- Elevance Health (Indianapolis, IN)
- …not eligible for employment based sponsorship. **Ensures accurate adjudication of claims , by translating medical policies, reimbursement policies, and clinical ... implications for system edits. + Coordinates research and responds to system inquiries and appeals . + Conducts research of claims systems and system edits to… more
- Humana (Atlanta, GA)
- …experience with MedHok, PaHub, and/or Service Read Only + Previous experience in medical claims processing + Previous inbound call center or related customer ... service experience + Previous grievance and appeals experience + Medical terminology experience +...+ Prior experience with Medicare + Experience with the Claims Administration System (CAS) + Ability to manage large… more
- St. Luke's University Health Network (Allentown, PA)
- …health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all diagnosis and procedure ... APR-DRG for the purpose of appealing proposed DRG and coding changes by insurance providers or their respective auditors JOB DUTIES AND RESPONSIBILITIES: + Conduct… more
- CommonSpirit Health (Centennial, CO)
- …for all care sites with external third-party payers to appeal denied claims and retrospectively identifies appeals determination as indicated through research ... and coordination of completion of medical records and utilization review processes. Identifies areas for...ability to adapt to ongoing changes within the health insurance industry in order to effect and implement positive… more
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