- CVS Health (Hartford, CT)
- …home) based anywhere in the US. Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part C appeals (both ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff *… more
- Molina Healthcare (Atlanta, GA)
- …8am-5pm PST hours** Must be able to rotate weekends and holidays** Must have Medicare Appeals and IRE experience** Responsible for reviewing and resolving member ... subrogation, and eligibility criteria. + Familiarity with Medicaid and Medicare claims denials and appeals processing, and...with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for … more
- Humana (Honolulu, HI)
- …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... established clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be passionate about… more
- 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 ... clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate about contributing… more
- US Tech Solutions (May, OK)
- …+ The role involves ensuring the accuracy of case setup and clinical review of Medicare appeals cases by thoroughly reviewing internal notes or fax requests for ... As an RPh Advisor you will be directly supporting Medicare Part D members and providers with requests related...and ensuring accurate decisions that comply with compendia and Medicare guidance and timelines. This is a great opportunity… more
- CVS Health (Phoenix, AZ)
- …1 years of experience in research and analysis of claim processing. - 1-2 years Medicare part C Appeals experience. - Project management skills are preferred. - ... issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from… 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 with ... delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances, enrollment, claims, pharmacy, and quality functions. You surface… more
- NTT DATA North America (Plano, TX)
- …Senior Manager to join our team. NTT DATA is seeking to hire a ** Medicare Appeals Clinical Leader** to lead service delivery engagements and improve end-to-end ... delivery of Medicare Appeals . Desire experience specifically for processes for clinical appeals coordinators but this role will be a leader in the end-to-end… more
- Guidehouse (Lewisville, TX)
- …and three days from home._** **Essential Job Functions** + Account Review + Appeals & Denials + Medicare /Medicaid + Insurance Follow-up + Customer Service ... + Billing + UB-04 & CMS 1500 + Complete all business-related requests and correspondence from patients and insurance companies. + Responsible for working on 40-70 Accounts Per Day + Complete all assigned projects in a timely manner. + Assist client and… more
- US Tech Solutions (RI)
- …volume where needed. **Responsibilities:** + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government ... clients or lines of business and in accordance with Medicare Part D CMS Regulations. + Must apply information...coverage requests. + Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed. +… more
- US Tech Solutions (May, OK)
- …volume where needed. **Responsibilities:** + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government ... requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations. Must apply information provided through multiple channels… more
- US Tech Solutions (May, OK)
- …based upon established standards. + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government mandated ... changing Med D guidance + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government mandated timelines +… more
- Eastern Connecticut Health Network (Vernon, CT)
- …performs concurrent audits for compliance with state regulations and assists in progressive appeals in Medicare Claims appeals as well as documentation ... of Agency Policy and Procedures. + In-depth knowledge of Medicare criteria. + Knowledge of reimbursement criteria. + Knowledge...management of payer and industry audits of claims and appeals process: + Assists in the review of all… more
- US Tech Solutions (May, OK)
- …authorizations. **Responsibilities:** + Ensure accuracy of case setup and clinical review of Medicare appeals cases. + Review internal notes or fax requests ... for clinical information to decision cases + Utilize work instructions and Medicare guidelines for accurate case processing. + Comply with CMS mandated timelines… more
- Mohawk Valley Health System (Utica, NY)
- …clinical variability throughout the medical staff. + Assist case managers with Medicare and Medicaid appeals and Administrative Law Judge (ALJ) testimonies. ... prevent denials or carved out days when appropriate. Provide telephonic and written appeals as requested for commercial payors. + Perform reviews and appeals .… more
- Centene Corporation (Carson City, NV)
- …Providers and Systems), HOS (Health Outcomes Survey), CTMs (Complaints to Medicare ), Disenrollment's, Appeals , and Grievances. + Collaborates with Provider ... enhances and maintains provider relationship across all product lines ( Medicare , Medicaid, Ambetter). Supports the development and implementation of quality… more
- Cognizant (Winston Salem, NC)
- …be 100% remote_ . The ideal candidate will have a good understanding in Medicare , Medicaid Claims, Appeals and Grievances, and Commercial Claims. With a focus ... industry regulations throughout the claims process. + Support the appeals and grievances process by providing accurate data and...an added advantage. + A strong understanding of Claims, Appeals and Medical Benefits + Proficiency in computer skills… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances Location: Los ... required to achieve that purpose. Job Summary The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is...LA Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …supervision of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced level work related to clinical denial management. ... conducting a comprehensive review of relevant clinical documentation. The Clinical Appeals Specialist will write compelling arguments based on clinical documentation… more
- Martin's Point Health Care (Portland, ME)
- …been certified as a "Great Place to Work" since 2015. Position Summary The Appeals Quality and Training Specialist supports the Appeals Department. This role ... goals through quality monitoring and training. This role partners directly with Appeals leadership to support on-going team development and growth. This role creates… more
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