- CareFirst (Baltimore, MD)
- …business needs and work activities/deliverables that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple ... managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances. **Preferred Qualifications:** + Applicants… more
- Point32Health (Canton, MA)
- …. **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...Marketing, Network Contracting, Legal, Servicing, Claims, Corporate Communications, and Medical Policy. The Director leads staff (managers… more
- CVS Health (Hartford, CT)
- …based (work at home) based anywhere in the US.**Responsibilities of this Medical Director role are related to Medicare Appeals .* Direct daily work on part C ... encumbrances* Board Certified in ABMS Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience.*… more
- State of Colorado (Denver, CO)
- …for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director . An appeal or review must be ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
- Martin's Point Health Care (Portland, ME)
- …member and provider appeals for review by clinical team, including medical director . + Prepares and sends appeal case files for all appeal levels ... Place to Work" since 2015. Position Summary Job Description Position Summary: The Appeals Specialist (Medicare or US Family Health Plan) is responsible for ensuring… more
- Fallon Health (Worcester, MA)
- …according to internal measures/targets. + Present appeals to the Fallon Health Medical Director (s) as appropriate. + Serve as the liaison between the ... appeals following the documented process. + Ability to review correspondence and system data to establish facts and... process; included but not limited to acquisition of medical records, status updates and final determination as indicated… more
- State of Colorado (Lakewood, CO)
- …for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director . An appeal or review must be ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
- Elevance Health (Woodland Hills, CA)
- …+ Extrapolates and summarizes medical information for medical director , consultants and other external review . + Prepares recommendations to either ... uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.… more
- Elevance Health (Woodland Hills, CA)
- …+ Extrapolates and summarizes medical information for medical director , consultants and other external review . + Prepares recommendations to either ... uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.… more
- LA Care Health Plan (Los Angeles, CA)
- …Procedures, in a consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all line of business ... This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as...evaluation by the Management Team. Duties Focus on quality review of grievance and appeals cases for… more
- CVS Health (Springfield, IL)
- …individual client requested coverage determinations or appeals when appropriate.- Medical Directors will participate in inter-rater review activities and ... Fortune 4 company, has an outstanding opportunity for a Medical Director - Medical Affairs....requested coverage determinations or appeals when appropriate.- Medical Directors will participate in inter-rater review … more
- Elevance Health (Columbus, OH)
- **Clinical Operations Medical Director ** **Utilization Management of Medical Oncology Benefits** **Carelon Benefits Management** **$20,000 Sign On Bonus** ... set of clinical domains, including radiology, cardiology and oncology._ The **Clinical Operations Medical Director supporting our Medical Oncology team** is… more
- City and County of San Francisco (San Francisco, CA)
- …health services, including psychiatric services. The Behavioral Health Services (BHS) Deputy Medical Director of Managed Care provides effective leadership and ... clinical responsibilities with the remaining 70-90% dedicated to Deputy Medical Director responsibilities, which include: + Supports...under Civil Service Rule 111A.35.1. The standard for the review of such appeals is 'abuse 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. + ... outcomes. A key component of this role is to review denials of care based on medical ...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- CVS Health (Columbus, OH)
- …and providers related to precertification, concurrent review , and appeal request. The medical director is a work-at-home position located anywhere in the US. ... reviews with peer to peer coverage of denials. * Appeals - The medical director ...Medicaid) Experience with managed care (Medicare and Medicaid) utilization review preferred MD or DO; Board certification in an… more
- Humana (Columbus, OH)
- …and will understand how to operationalize this knowledge in their daily work The Medical Director 's work includes computer-based review of moderately complex ... caring community and help us put health first** The Medical Director actively uses their medical...group practice management. + Utilization management experience in a medical management review organization, such as Medicare… more
- City and County of San Francisco (San Francisco, CA)
- …service examination process is subject to change after adoption (eg, as a result of appeals ), as directed by the Human Resources Director or the Civil Service ... under Civil Service Rule 111A.35.1. The standard for the review of such appeals is 'abuse of...item(s) constitute(s) abuse of discretion by the Human Resources Director . Appeals must be submitted directly to… more
- CVS Health (Columbus, OH)
- …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 provider appeals clinical review .* Actively participate in scheduled team… more
- Elevance Health (Denver, CO)
- … reviews within our Medicaid and Medicare programs.** The **Behavioral Health Medical Director ** is responsible for the administration of behavioral health ... opportunities. May serve as a resource to staff including Medical Director Associates. How you will make...or territory of the United States when conducting utilization review or an appeals consideration and cannot… more
- City and County of San Francisco (San Francisco, CA)
- …service examination process is subject to change after adoption (eg, as a result of appeals ), as directed by the Human Resources Director or the Civil Service ... under Civil Service Rule 111A.35.1. The standard for the review of such appeals is 'abuse of...item(s) constitute(s) abuse of discretion by the Human Resources Director . Appeals must be submitted directly to… more