• Director , Appeals

    Point32Health (Canton, MA)
    …(https://youtu.be/S5I\_HgoecJQ) . **Job Summary** Under the general direction of the VP, the Appeals and Grievances Director is responsible for management ... and oversight of the Enterprise Member Appeals and Grievances Department. The Director is responsible for all aspects of the member appeals and grievance… more
    Point32Health (04/11/24)
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  • Nurse Appeals (RN)

    Elevance Health (Woodland Hills, CA)
    …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
    Elevance Health (05/26/24)
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  • Customer Solution Center Appeals

    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
    LA Care Health Plan (05/22/24)
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  • Medicare Grievances and Appeals

    Humana (Columbus, OH)
    Director relies on medical background and reviews 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 about the appropriateness of services… more
    Humana (05/02/24)
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  • Medical Review & Appeals Director

    CareFirst (Baltimore, MD)
    …health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances . **Preferred Qualifications:** + Applicants with specific ... of the interdependencies between Medical Policy, Clinical Medical Review and Appeals and Grievances . + Ability to mentor and coach associates to accomplish… more
    CareFirst (05/07/24)
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  • Director - USFHP Clinical Operations

    Pacific Medical Centers (Seattle, WA)
    appeals for presentation. Decision maker for all post service, network and benefit appeals . Acts as second level manager for grievances . Works with patients ... **Description** **Overview:** The director provides leadership for USFHP clinical operations: including...presentation. Decision maker for all post-services, network and benefit appeals . Acts as second-level manager for grievances .… more
    Pacific Medical Centers (05/18/24)
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  • Medical Director , Highmark Health Options…

    Highmark Health (Charleston, WV)
    …them to assure ongoing relationships with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the evaluation and resolution of ... the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. +... grievances and appeals of patients, providers, and… more
    Highmark Health (05/16/24)
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  • Medical Director , Medical Management

    LA Care Health Plan (Los Angeles, CA)
    …discharge planning, transitions of care, complex care rounds, interdisciplinary care team rounds, appeals and grievances and provider disputes. On day to day ... Medical Director , Medical Management Job Category: Clinical Department: Utilization...care management functions including care team rounds. Review of appeals , grievances and provider disputes. Provide strategic… more
    LA Care Health Plan (05/23/24)
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  • Director Employee Relations - Office…

    Gwinnett County Public Schools (Suwanee, GA)
    …of Employee Relations will assist in providing resolution in matters related to grievances and appeals , training and development to administrators and employees ... Director Employee Relations - Office of Employee Relations...on equity, compliance, accommodation, grievances , and Title IX.1. Leads equal opportunity and other… more
    Gwinnett County Public Schools (04/23/24)
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  • Clinical Director - Summit Youth Services…

    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, ... Clinical Director - Summit Youth Services Center in Golden...relevant standards of policy and procedure, resolves informal staff grievances , creates and monitors staff work schedules, participates in… more
    State of Colorado (05/22/24)
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  • Senior Medical Director

    CVS Health (Columbus, OH)
    …Fair Hearings as needed. Understand UM and participate in UM front line work and appeals as needed in OH and other markets as needed* Confer directly with providers ... illnesses through peer review and educational interventions.* Work with medical director teams focusing on inpatient care management, clinical coverage review,… more
    CVS Health (04/13/24)
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  • Psychiatrist Senior Medical Director

    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 aspects of the...with the Counties and DHS + Reviews complaints and grievances in accordance with Community Care procedures and ensures… more
    UPMC (04/16/24)
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  • Clinical Assistant/Associate/Full Professor…

    New York University (NY)
    …of Professional Studies seeks a Clinical Assistant/Associate/Full Professor and Academic Director for the Schack Institute of Real Estate, effective Fall 2024. ... of Real Estate, the successful candidate will also serve as the Academic Director to implement the vision for expanding Schack's real estate programs and… more
    New York University (03/15/24)
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  • Executive Medical Director Revenue Cycle

    AdventHealth (Maitland, FL)
    …makes recommendations on appealed provider claims and makes determinations for appeals & grievances from members.Provides support, shares administrative call, ... **The role you'll contribute:** As the physician advisor, the Executive Medical Director of Revenue Cycle educates, informs, and advises members of the Case… more
    AdventHealth (05/18/24)
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  • Family Nurse Practitioner (FNP) Program…

    Thomas Edison State University (Trenton, NJ)
    …and faculty deployment. -Respond to student concerns to resolve conflicts, appeals , and disputes/ grievances . -Assist with preparation of self-study report ... **Family Nurse Practitioner (FNP) Program Director ** **D30** Thomas Edison State University was founded...opportunities, should submit an application. **Summary:** The FNP Program Director reports directly to the Dean, W. Cary Edwards… more
    Thomas Edison State University (03/28/24)
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  • Director of Human Resources (Facilities…

    University of Massachusetts Amherst (Amherst, MA)
    Director of Human Resources (Facilities & Campus Services) (Hybrid Opportunity) Apply now ... adds to the intellectual energy of the region. Job Summary As the Director of Human Resources Facilities & Campus Services (F&CS) Service Center, manages effective… more
    University of Massachusetts Amherst (04/17/24)
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  • Medical Director (Behavioral Health)…

    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 ... and concises rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
    Highmark Health (03/05/24)
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  • Patient Representative Services Program…

    Bassett Healthcare (Cooperstown, NY)
    …for Bassett Healthcare Network. The Program Coordinator processes and analyzes patient grievances and complaints through the network. The PRS Program Coordinator is ... position is responsible for ensuring that patient/visitor concerns or grievances are processed and resolved in a timely manner...care concerns and reports them immediately to the appropriate director . This includes, but is not limited to complaint… more
    Bassett Healthcare (05/24/24)
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  • Mgr, Member Engagement-Medicare-NY City-Field

    Molina Healthcare (New York, NY)
    …Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances , Member Problem Research and Resolution, and the ... + Collaborates with operational areas involving member impact and engagement including: Appeals and Grievances , Member Inquiry Research and Resolution, and… more
    Molina Healthcare (04/24/24)
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  • CDOC Health Service Administrator

    State of Colorado (Pueblo, CO)
    …of notice or knowledge of the action: Colorado State Personnel Board/State Personnel Director , Attn: Appeals Processing, 633 17th Street, Suite 1320, Denver, CO ... reviews, and completing performance evaluations per CDOC regulations, and resolves complaints/ grievances at the informal level; + Ensures staff compliance with the… more
    State of Colorado (05/17/24)
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