- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, September 9, 2024 Centers Plan for Healthy ... plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex...in writing. + Analyze and complete written summaries on clinical cases. EDUCATION AND EXPERIENCE: Education: RN … more
- VNS Health (Manhattan, NY)
- …Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + ... and audits subcontractors who have delegated responsibility for managing grievance and appeals on behalf of the...+ License and current registration to practice as a registered professional nurse in New York State… more
- Commonwealth Care Alliance (Boston, MA)
- …to appeal and grievances. **What You'll Be Doing:** - Processing of Grievances & Appeals . - Responsible for the progress of grievance and appeal intervention and ... strict deadlines. - When necessary collaborate with care teams, clinical staff, family members, and other involved in providing...dental, reporting, and member services. - Supports the Senior Appeals & Grievance Coordinator and A/G Coordinator… more
- LA Care Health Plan (Los Angeles, CA)
- …The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse ( RN ) II provides direct assistance to member's with ... Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC...agencies. Good working knowledge of regulatory requirements/standards. Licenses/Certifications Required Registered Nurse ( RN ) - Active,… more
- Elevance Health (Rancho Cordova, CA)
- ** Nurse Appeals - Licensed RN Nurse ** **Location:** This position will work in a hybrid model (remote and office). Ideal candidates will live in the ... PulsePoint locations. **Shift:** Monday to Friday from 8:00-5:00 pm PT The ** Nurse Appeals ** is responsible for investigating and processing medical necessity… more
- CDPHP (Albany, NY)
- …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and ... of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity...external review, and making recommendations for change. QUALIFICATIONS: + Registered Nurse , Physician Assistant or Nurse… more
- Commonwealth Care Alliance (Boston, MA)
- …oversight, and compliance. + Develop and execute on strategic opportunities to improve appeals & grievance process to support a best-in-class A&G operation that ... to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances, the Manager, Appeals &...Director. Partner with A&G Operations Manager and the A&G Clinical Manager to performroot cause analysis of identified issues… more
- Actalent (Rancho Cordova, CA)
- …or as clinically appropriate + Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary + Assists in ... for members with urgent needs + Prepares and submits clinical review cases to Medical Director (MD) for medical...Utilization Management, Interqual Additional Skills & Qualifications: + CA RN License required + 5+ years of RN… more
- CareFirst (Baltimore, MD)
- …requirements. + Appeals , Grievances & Clinical Medical Review: Oversees the Appeals and Grievance function as well as Clinical Medical Review for ... Case Management, Utilization Management including prior authorization, and post service clinical medical review and Appeals & Grievances operational functions… more
- The Cigna Group (Bloomfield, CT)
- …duties as assigned. **Qualifications** + Education: Licensed Practical Nurse (LPN) or Registered Nurse ( RN ) + 3-5 years' experience in Medicare Advantage ... (Tuesday ALT Day).** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part...as well as research and provide a written detailed clinical summary for the Plan Medical Director. + Determine… more
- UPMC (Pittsburgh, PA)
- … experience. + Managed Care Experience preferred. **Licensure, Certifications, and Clearances:** + Registered Nurse ( RN ) + Act 31 Child Abuse Reporting ... appeals , member grievances, & DPW requests.Participates in telecons, grievance hearings, and DPW pre-hearings/hearings.Reviews and completes MA late...Human Services or related field with 3 years of clinical experience **Or** + RN with 3… more