- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances ... net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for… more
- CareFirst (Baltimore, MD)
- …in a managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances . **Preferred Qualifications:** + ... + Understanding of the interdependencies between Medical Policy, Clinical Medical Review and Appeals and Grievances . + Ability to mentor and coach… more
- Elevance Health (Hendersonville, TN)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... for medical necessity. + Extrapolates and summarizes medical information for medical director ,...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Elevance Health (Rancho Cordova, CA)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... for medical necessity. + Extrapolates and summarizes medical information for medical director ,...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... ongoing relationships with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the...There are a variety of external contacts that the Medical Director would be anticipated to regularly… 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… more
- CVS Health (Columbus, OH)
- …resistant illnesses through peer review and educational interventions.* Work with medical director teams focusing on inpatient care management, clinical ... coverage review, member appeals clinical review, medical claim review, and...the investigation of potential quality of care concerns and/or grievances * Actively support compliance functions to maintain standardized systems,… more
- UPMC (Moosic, PA)
- We have an exciting opportunity for a full-time Senior Medical Director to join our leadership team with UPMC Community Care! As Senior Medical Director , ... you to learn more and apply today! The Senior Medical Director provides guidance for clinical operational...with the Counties and DHS + Reviews complaints and grievances in accordance with Community Care procedures and ensures… more
- Guardian Life (Plano, TX)
- …applicable state regulations. In this role, you will ensure that referrals, appeals , and grievances meet state specific regulations, timeframes, and definitions ... The **Texas State Dental Director ** will be responsible for ensuring that professional...the regulators. You will Review Specialty Referrals, Claims & Appeals + Review & ensure that determination and processing… more
- AdventHealth (Maitland, FL)
- …Site position** **The role you'll contribute:** As the physician advisor, the Executive Medical Director of Revenue Cycle educates, informs, and advises members ... related to denial prevention measures for our contracted managed care payers. The Medical Director is responsible for providing physician review of utilization,… more
- Gwinnett County Public Schools (Suwanee, GA)
- …to, discrimination, Title IX, and requests for accommodations on the basis of a medical impairment. The Director of Employee Relations will assist in providing ... Director Employee Relations - Office of Employee Relations...resolution in matters related to grievances and appeals , training and development to… more
- Highmark Health (Dover, DE)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… more
- Bassett Healthcare (Cooperstown, NY)
- …process. Maintains expert knowledge and shares knowledge regarding CMS, TJC, Rural Medical Clinics, and NYSDOH regulations, related to grievances and complaints, ... issues. Recognizes potential liability issues and reports them to the appropriate director ; completes medical malpractice event reports. Develops and uses… more
- CareOregon (Portland, OR)
- …for Transportation services covered under Medicaid and Medicare lines of business, including appeals and grievances , as well as data reporting. This includes ... Manager in the development of short and long-term quality planning. + Guide appeals and grievances work across Transportation team and subcontracted partners and… more
- The Cigna Group (Nashville, TN)
- …well as research and provide a written detailed clinical summary for the Plan Medical Director . + Determine whether additional pre service, appeal or grievance ... will include requests for decisions regarding denials of medical services as well as Part B drugs. The...C + Ability to differentiate different types of requests Appeals , Grievances , coverage determination and Organization Determinations… more
- Universal Health Services (Riverside, CA)
- …all locations to maintain AAAHC "readiness". 7. Assist Manager, Quality, and/or Regional Director , Quality and/or Medical Director with special projects. 8. ... QRMC and MPC preparation 11. Any other responsibilities requested by Manager, Regional Director , and Medical Director . EEO Statement:All UHS subsidiaries… more
- State of Colorado (Golden, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to… more
- State of Colorado (Denver, CO)
- …answers phone, order office and medical supplies, distribute and track medical grievances , arrange for repair of office equipment, monthly reporting, sort ... CDOC Medical Records Technician I - PART-TIME- (Denver) Print...Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... of notice or knowledge of the action: Colorado State Personnel Board/State Personnel Director , Attn: Appeals Processing, 1525 Sherman Street, 4th Floor, Denver,… more
- State of Colorado (Arapahoe County, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... This supervision entails assigning and evaluating work, handling informal grievances , initiating corrective and disciplinary actions, and participating in the… more