- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Corporate Medical Director (CMD) relies on medical background to review health claims ... and preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate… more
- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims and ... preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Molina Healthcare (Columbus, OH)
- …with the standards and requirements established by the Centers for Medicare and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the ... activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized… 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 ... Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care....experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… 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
- Molina Healthcare (Columbus, OH)
- **JOB DESCRIPTION** **Job Summary** The Medical Director for Specialty Medical Services & Market Performance will provide clinical expertise and support to ... activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +...Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.… more
- Beth Israel Lahey Health (Burlington, MA)
- …1 Transplant Administrators meetings. **Strategic** 1. In conjunction with the Chairs, Medical Directors and Executive Director , is responsible for business ... and Managers in establishing department policies and procedures. 3. Works with Chairs, Medical Directors, Executive Director and Managers on the development of… more
- Martin's Point Health Care (Portland, ME)
- …has been certified as a "Great Place to Work" since 2015. Position Summary The VP Medical Director of Clinical Programs will manage the Health Plan Medical ... government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice + Works...areas of MHPC, as needed + Assists the Market Medical Director for building and deepening relationships… more
- Somatus (Mclean, VA)
- …provides guidance and oversight to all lines of business including Commercial, Medicaid, Medicare , and Special Need Plans (SNPs). The Director , Quality will work ... the best version of themselves, including: + Subsidized, personal healthcare coverage ( medical , dental vision) + Flexible Paid Time Off (PTO) + Professional… more
- Bassett Healthcare (Herkimer, NY)
- …the best quality of life possible. What you'll do The primary purpose of the Director of Social Services is to plan, organize, develop the Social Services Program in ... receive the highest degree of care while their social, medical and emotional needs and rights are met. The...to benefit from his/her stay with the facility. The Director of Social Services will be involved with the… more
- State of Colorado (Denver, CO)
- …Job About the Position: This position exists to conduct follow-up regarding grievances , investigate incident reports accordingly, review and analyze data and share ... or verbal client complaints assigned to them by the Supervisor or Facility Director , and strictly adhering to established timelines, will meet with the client and,… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… more
- Mary Greeley Medical Center (Ames, IA)
- …and meet regulatory requirements. + Reports any observed or suspected deviation from medical center policies or from Medicare , Medicaid, or other insurance ... regulations immediately to the department Manager, Director , or the medical center's Compliance Officer....Compliance Officer. + Reports any concerns regarding patient care grievances to the Manager or Director . +… more
- State of Colorado (Denver, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- CareOregon (Portland, OR)
- …Division of Medical Assistance Programs (DMAP) and the Centers for Medicare and Medicaid Services (CMS) rules and regulations + Experience with NCQA ... Requisition # 24958 Direct Reports Team Supervisors and Support Staff Manager Title Director , Clinical Operations Pay & Benefits Estimated hiring range $ 135,420 -… more
- LA Care Health Plan (Los Angeles, CA)
- …the Regulatory Compliance unit, the Advisor also advises and supports the Manager, Director , and Chief Compliance Officer on other duties as assigned to support the ... Experience in health care auditing and monitoring (preferably in Appeals, Grievances , Quality Improvement, Utilization Management (UM) and so forth) and developing… more
- Tufts Medicine (Boston, MA)
- …clinical trial budgets with sponsors and assists with the completion of Medicare Coverage Analyses. 4. Keeps abreast of new and modified sponsor regulations ... of fiscal state of research program/laboratories and makes recommendations to PIs and director for planning purposes. 9. Meets regularly with director and PIs… more
- Molina Healthcare (Columbus, OH)
- …Tighter knit proximity ongoing after contract. * In conjunction with Director /Manager, Provider Contracts, negotiates Complex Provider contracts including but not ... software. * Targets and recruits additional providers to reduce member access grievances . * Engages targeted contracted providers in renegotiation of rates and/or… more