- CVS Health (Hartford, CT)
- …in the US.**Responsibilities of this Medical Director role are related to Medicare Appeals .* Direct daily work on part C appeals (both provider and ... policy for the enterprise* Provide ongoing education regarding Medicare policy and appeals to the appeal...Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience.* Health… more
- Corewell Health (Grand Rapids, MI)
- …met. + Act as lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria ... Health - 1239 E Beltline - Grand Rapids Department Name PH - Grievance And Appeals Medicare Employment Type Full time Shift Day (United States of America) Weekly… more
- CareFirst (Baltimore, MD)
- …Strategic Plan through direction of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs ... needs and work activities/deliverables that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical… more
- Martin's Point Health Care (Portland, ME)
- …on clinical member and provider appeals for review by clinical team, including medical director . + Prepares and sends appeal case files for all appeal levels ... manner. The Specialist communicates and collaborates with Case Managers, Medical Directors and Compliance partners, as well as other...Health Plan benefits, particularly as it relates to Member Appeals + Cross-trains with Medicare Appeals… more
- Trinity Health (Darby, PA)
- **Employment Type:** Full time **Shift:** Day Shift **Description:** The Appeals and Utilization Management Coordinator under direction and in collaboration with the ... Manager, provides support to the utilization management, denials and appeals process for the THMA South hospitals. The ...are met + Collaborates with Physician Advisor to clarify medical necessity or clinical rationale + Assists in corresponding… more
- Banner Health (AZ)
- …appeal information from appropriate individuals that would include employees, providers, Medical Director , Plan Administrator, RNs, Risk Management, attorneys, ... **Primary City/State:** Arizona, Arizona **Department Name:** Grievances & Appeals **Work Shift:** Day **Job Category:** General Operations The future is full of… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance with… 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 ... materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of… more
- Elevance Health (Richmond, VA)
- …office locations Work schedule: Monday - Friday, standard business hours.** The Medical Director Clinical Programs is responsible for designing and implementing ... of Elevance Health's family of brands, offering Medicaid and Medicare plans in several states. We also provide administrative...clinical programs with specific medical condition focus for all lines of business enterprise… more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and… 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...reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and … more
- Intermountain Health (Murray, UT)
- …divisions as needed to implement policies and programs for the Office of the Medical Director to manage the provider panel and to maintain high customer ... satisfaction. This position reports to the Medical Director , SelectHealth. Job Essentials 1. Coverage...or quality of care. Work as primary reviewer for Medicare and Medicaid appeals . 2. Quality of… more
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the evaluation and resolution of...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- CVS Health (Springfield, IL)
- …will perform concurrent and prior authorization reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals in ... services to its membership. Aetna is looking for a Medical Director to be part of a...Two (2) + years of experience in managed care ( Medicare and/or Medicaid) Experience with managed care ( Medicare… more
- LA Care Health Plan (Los Angeles, CA)
- Medical Director , Medical Management Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time ... net required to achieve that purpose. Job Summary The Medical Director , Medical Management, is...of care, complex care rounds, interdisciplinary care team rounds, appeals and grievances and provider disputes. On day to… more
- Molina Healthcare (Bothell, WA)
- …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
- Molina Healthcare (Bothell, WA)
- …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
- Centers Plan for Healthy Living (Staten Island, NY)
- …and HHCAHPS sites to obtain quality data. + Oversight of Medicare Expedited appeals and conventional Medicare appeals process. Maintains records of all ... Director Quality Management/Compliance Officer 75 Vanderbilt Ave, Staten...appeals . Serves as the Agency's contact with the Medicare QIO. + Oversight of risk management, including documentation… more
- Lancaster General Health (Lancaster, PA)
- **Summary** **Job Description** **POSITION SUMMARY:** The Associate Medical Director , Hospitalist Services is responsible for assisting the Medical ... The Associate director will report to LGHP Medical Director and have a reporting relationship...their satisfaction with LRH's services + Provide assistance with appeals of claims denied by government and other third-party… more
- AmeriHealth Caritas (Newark, DE)
- ** Medical Director , LTSS (must reside in DE)** Location: Newark, DE Primary Job Function: Medical Management ID**: 34195 **Job Brief** Qualified candidates ... and related policy and practice initiatives in collaboration with the Corporate Medical Director (s), Senior Medical Directors, Utilization Management and… more