- CVS Health (Hartford, CT)
- …based (work at home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Part C Medicare Appeals . This position is ... however the expectation is to cross train for regulated appeals . * Provide support to Medicare appeal...Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience. *… more
- Humana (Columbus, OH)
- … (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… more
- Humana (Columbus, OH)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Molina Healthcare (Columbus, OH)
- …direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements ... for Medicare and Medicaid Services. * Trains grievance and appeals staff, customer/member services department, sales, UM and other departments within Molina… more
- Penn Medicine (Philadelphia, PA)
- …quarterly denial reports by service as requested. Coordinator participates in Medicare and Medicaid chart reviews for medical necessity. **Credentials:** ... the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and...you living your life's work? **Summary:** + The Clinical Appeals Coordinator will play an essential role in maximizing… more
- Mount Sinai Health System (New York, NY)
- **Job Description** The Senior CBO Appeals Analyst position requires an in-depth knowledge of healthcare pricing/reimbursement processes and procedures including ... collaboration with the Underpayment Team manager, the Senior CBO Appeals Analyst will work to further the CBO's goals...meetings. 6. Routinely meets with underpayment team manager and director to provide updates on KPI's. 7. Research and… more
- Centene Corporation (Jefferson City, MO)
- …including a fresh perspective on workplace flexibility. + **Position Purpose:** Assist the Medicare Chief Medical Officer to develop and implement our enterprise ... executives and the ROI behind clinical initiatives. Must understand Medicare and Medicaid, prior Health plan experience is a... and pharmacy consultants for reviewing complex cases and medical necessity appeals . + Participate in provider… more
- Molina Healthcare (Columbus, OH)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Elevance Health (Metairie, LA)
- ** Medicare Medical Director - Part...the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... Candidates must be able to work Eastern Time Zone hours. The ** Medicare Medical Director ** is responsible for the administration of physical and/or… more
- Centene Corporation (Jefferson City, MO)
- …including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical ... implementation of performance improvement initiatives for capitated providers. + Assists Chief Medical Director in planning and establishing goals and policies… more
- Humana (Columbus, OH)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and … more
- Humana (Columbus, OH)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Fortune 6 company, has an outstanding opportunity for a Medical Director ( Medical Affairs). This...individual client requested coverage determinations or appeals when appropriate. - Medical Directors will… more
- Molina Healthcare (Columbus, OH)
- **JOB DESCRIPTION** **Job Summary** The Medical Director for Specialty Medical Services & Market Performance will provide clinical expertise and support to ... the enterprise. Primary responsibilities will include specialized medical necessity reviews and/or appeals and supporting...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Centene Corporation (Dover, DE)
- …and Supports (LTSS) and Medicare -Medicaid Duals populations. Additionally, the Medical Director will collaborate with other key stakeholders to provide ... with the LTSS Director and Care Coordination Director to manage and optimize LTSS and Medicare...LTSS Only:** A full-time Long Term Services and Supports Medical Officer/ Medical Director (LTSS CMO)… more
- Humana (Columbus, OH)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...group practice management. + Utilization management experience in a medical management review organization, such as Medicare … more
- Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)
- …and Second Level Administrative Appeals as directed by the Senior Medical Director . + Completes required training activities in a timely manner. ... people + This role reports to this job: SENIOR MEDICAL DIRECTOR (MGR) + Necessary Contacts: department...initial and appeal and the related procedure. + Performs medical or administrative appeals as needed based… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... for all of Sharp Health Plan products, (Commercial, Exchange, Medicare , POS/PPO) services, and oversees the health care needs...+ 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …and implementation of the Children's Behavioral Health (BH) Carve-In program. The Medical Director for BH Children's Services has overall accountability for ... of the Quality Management/Utilization Management (QM/UM) Plan, including having the BH Medical Director for Children's Services and participate on the BH… more
- Medical Mutual of Ohio (Brooklyn, OH)
- …overseeing all activities related to the third-party administration of self-funded medical , dental, and specialty benefits. Additionally, the Director ... with additional in-office presence as needed._** Founded in 1934, Medical Mutual is the oldest and one of the...self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.… more