- RestoraCare Staffing (Houston, TX)
- …to achieve continuous improvement in both areas. Refers cases and issues to Care Management Medical Director in compliance with department procedures and follows ... management , case management , performance improvement, disease or population management and managed care reimbursement. Understanding of pre-acute and… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...documented on all patient medical records. 6. Coordinates with Care Management team when cases do not… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals / Care /Case/Utilization Management /Quality. Strong verbal and written ... in Nursing Experience Required: Minimum of 8 years of acute/ clinical care experience. Minimum of 2 years...in a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute… more
- HCA Healthcare (Nashville, TN)
- …**Introduction** Do you want to join an organization that invests in you as a Clinical Appeals Team Lead? At Parallon, you come first. HCA Healthcare has ... and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. +...make a difference. We are looking for a dedicated Clinical Appeals Team Lead like you to… more
- Trinity Health (Farmington Hills, MI)
- …length of stay, level of care , missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed ... causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals...experience, to include two (2) years of utilization review/case management , managed care or comparable patient payment… more
- CareFirst (Owings Mills, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding ... adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical ...Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred. + BSN/MSN Degree. **Knowledge,… more
- HCA Healthcare (Brentwood, TN)
- **Description** **Introduction** Do you have the career opportunities as a Clinical Appeals Nurse RN you want with your current employer? We have an exciting ... and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. +...of colleagues. Do you want to work as a Clinical Appeals Nurse RN where your passion… more
- Penn Medicine (Philadelphia, PA)
- …of the Clinical Appeals Coordinator in all phases of the Clinical Quality and Utilization Management functions including but not limited to data entry, ... your life's work? **Summary:** Responsible for coordinating office activities for the Clinical Appeals Coordinators to assist the department in accomplishing the… more
- Martin's Point Health Care (Portland, ME)
- …well as other internal teams and external partners to ensure a comprehensive appeals management process. Medicare Focus Key Outcomes: + Processes, researches, ... the Medicare subject matter expert for the Medicare Managed Care Manuals pertaining to Part C appeals ...providers and third-party administrators. + Prepares case files on clinical member and provider appeals for review… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, April 29, 2024 Centers Plan for Healthy Living's goal is ... a managed care environment in related area of responsibility, (ie utilization management , quality management , grievances, and appeals ) Type of Experience… more
- CVS Health (Columbus, OH)
- …educational interventions.* Work with medical director teams focusing on inpatient care management , clinical coverage review, member appeals clinical ... and other complex health populations to optimize risk adjustment, clinical quality, and care management *...review, medical claim review, and provider appeals clinical review.* Actively participate in scheduled team meetings and… more
- Universal Health Services (Chicago, IL)
- …SUMMARY: Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals , Standard Appeals , External ... Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally recognized criteria to… more
- Elevance Health (Denver, CO)
- …to attend a town hall office meeting once a quarter. The **Pharmacist - Clinical Appeals ** is responsible for managing the selection and utilization of ... pharmaceuticals and supports core clinical programs such as DUR. Primary duties may include,...in Pharmacy. + Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of… more
- Kepro (Indianapolis, IN)
- …health solutions in the public sector. Acentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our growing team. Job Summary: ... Our Utilization Management Appeals Nurse - LPN/RN will help...of Indiana or a Compact license. + Previous healthcare/managed care Appeals experience. + 2+ years of… more
- LA Care Health Plan (Los Angeles, CA)
- …in a consistent and accurate manner. This position will focus on quality review of non- clinical grievance and appeals cases for all line of business (LOB) to ... Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job...$87,342.00 (Mid.) - $107,498.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created… more
- LA Care Health Plan (Los Angeles, CA)
- …Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the… more
- Point32Health (Canton, MA)
- …. **Job Summary** Under the general direction of the VP, the Appeals and Grievances Director is responsible for management and oversight ... doing** + The Director is responsible for leading the Appeals and Grievance Department management team and...**Experience** + Required (minimum): 10-15 experience in a managed care setting. Five to seven years of management… more
- Magellan Health Services (San Diego, CA)
- Coordinates appeals process as assigned, attends to risk management issues associated with case management and processes appeal requests. In some cases may ... day compliance of appeal decision time frames. + Reviews clinical and medical records for completeness and determines administrative...medical necessity reviews. + Enters all data related to appeals and case reviews into a database. + Prepares… more
- CVS Health (Hartford, CT)
- …Utilization Management Staff* Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency Required Qualifications * Two ... system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.**This is a… more
- CareFirst (Baltimore, MD)
- … Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead ... week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical ...Licensure And/or Compact State Licensure. **Experience:** + 8 years clinical experience in care management .… more
