- Molina Healthcare (Des Moines, IA)
- …including 3 years in a manager role. * Experience with Medicare Regulations, Medicare Duals, Appeals & Grievances , Provider Disputes (Par and Non-Par) ... for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that...requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures… more
- Molina Healthcare (Des Moines, IA)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements… more
- Humana (Des Moines, IA)
- …Director (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 appropriateness and… more
- Humana (Des Moines, IA)
- … 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 appropriateness of services… more
- Molina Healthcare (Des Moines, IA)
- …or related field (advanced degree a plus). **Experience** * 7+ years managing Medicare CTM, appeals & grievances , or related compliance functions-hands-on ... must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and...SLA tracking, and program audits. * Deep knowledge of Medicare regulations affecting complaints, grievances , and member… more
- Molina Healthcare (Des Moines, IA)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more