- Elevance Health (Indianapolis, IN)
- ** Nurse Appeals ** **Location: Indiana** **Virtual:** This role enables associates to work virtually full-time, with the exception of required in-person training ... employment, unless an accommodation is granted as required by law. The ** Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances Location: Los ... the safety net required to achieve that purpose. Job Summary The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily… more
- CareFirst (Baltimore, 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 skills and knowledge of all applicable State and Federal rules and… more
- CVS Health (Columbus, OH)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... will be responsible for processing the medical necessity of Medicare appeals for participating providers. **Key Responsibilities** + Requesting clinical, research,… more
- University of Washington (Seattle, WA)
- …Medicine's Patient Financial Services Department** has an outstanding opportunity for a **Clinical Appeals and Disputes Nurse .** **WORK SCHEDULE** + 100% FTE + ... 100% Remote + Days **POSITION HIGHLIGHTS** The Clinical Appeals and Disputes Nurse ensures that payers are prepared to reimburse the UW Medicine for services in… more
- Evolent (Springfield, IL)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- BronxCare Health System (Bronx, NY)
- Overview The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and electronic ... format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal Manager is responsible to develop a… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Appeals Specialist I is responsible for the initial analysis of appeals and grievance correspondence, and ... collecting, organizing and tracking information to facilitate and expedite processing of appeals and grievances received from a variety of sources. We are looking… more
- BJC HealthCare (St. Louis, MO)
- …experience) **Additional Information About the Role** BJC HealthCare is seeking a Clinical Appeals Specialist to assist with infusion appeals for both government ... be handling clinical denials and sending them to a nurse to review and appeal and then they will...clinical denials for BJC hospitals and payors. The Clinical Appeals Specialist must be able to multi-task and maintain… more
- LA Care Health Plan (Los Angeles, CA)
- Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017 Position ... net required to achieve that purpose. Job Summary The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a… more
- Centene Corporation (Trenton, NJ)
- …Zone.** **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical ... + Communicates with members, providers, facilities, and other departments regarding appeals requests + Generates appropriate appeals resolution communication and… more
- CareFirst (Baltimore, MD)
- …with dynamic goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance departmental capabilities. Accountable ... and accreditation requirements. Ensures appropriate and complete resolution of appeals , Regulatory complaints and External review requests. Performs analytics and… more
- CareFirst (Baltimore, MD)
- …& Qualifications** **PURPOSE:** We are looking for a Director, Medical Review & Appeals for our Government Programs lines of business. The incumbent will ensure ... through direction and oversight of the Clinical Medical Claims Reviews, Clinical Appeals and Analysis programs and Quality of Care complaints in conjunction with… more
- BronxCare Health System (Bronx, NY)
- …the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to ... identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and… more
- McLaren Health Care (Mount Pleasant, MI)
- …. Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews ... of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer appeal/filing deadlines are met and achieve optimal payment for… more
- St. Luke's University Health Network (Allentown, PA)
- …a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all ... formal meetings with auditor or payor representatives in defense of coding appeals , as needed. + Maintain necessary audit/appeal activity documents including Excel… more
- Nuvance Health (Danbury, CT)
- *Description* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12-24 hours ... notice of conversion, etc. * Tracking and trending all appeals and communicating on a daily/regular basis with the...* Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum of… more
- State of Indiana (Indianapolis, IN)
- Appeals & Eligibility Specialist Date Posted: Oct 16,...requirements at 42 CFR 483.430, or - A registered nurse in Good Standing with the State of Indiana ... plus one year's experience in human services; or- A bachelor's degree in social work, psychology, sociology, counseling, gerontology, or nursing; or health and human services or a bachelor's degree in any field plus a minimum of two years' full-time… more
- Northwell Health (Melville, NY)
- …current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness ... job entry date. + Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. + Inpatient… more
- Northwell Health (Melville, NY)
- …current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness ... of job entry date. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. *Additional… more