- VNS Health (Manhattan, NY)
- …the administration of all BH QM/UM and performance improvement activities, encompassing grievances and appeals , and contributes to various other subcommittees ... such as Compliance and Pharmacy.Develops, implements, monitors and evaluates Utilization and Care Management metrics specific to Behavioral health services across all plan types as necessary. This process includes the formulation of specific objectives and key… more
- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances , the Manager, Appeals & Grievances (A&G) ... Audit and Oversight is responsible for the oversight of Plan level appeals and grievances within the Appeals & Grievances Department and delegated… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Customer Solution Center Appeals and Grievances Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, ... achieve that purpose. Job Summary The Supervisor, Customer Solution Center Appeals and Grievances is responsible for direct supervision and support of the team… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, ... to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, ... to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Specialist II will receive, investigate and resolve member and… more
- Generac Power Systems (Waukesha, WI)
- …into an energy technology solutions company, we continue to push new boundaries. The ** Appeals and Grievances Specialist** is a critical team player who is ... under general supervision with some guidance from leadership and higher-level Appeals and Grievances Specialists. **Job Responsibilities:** Case Resolution +… more
- Insight Global (Los Angeles, CA)
- Job Description The Supervisor of the Customer Solution Center Appeals and Grievances is responsible for directly supervising and supporting the team that ... handles the intake, research, resolution, tracking, trending, and reporting within the Appeals and Grievances department. This role involves leading and… more
- Insight Global (Los Angeles, CA)
- Job Description The Customer Solution Center Appeals and Grievances Specialist I will support the Appeals and Grievances team to receive, investigate and ... -Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for… more
- Elevance Health (Los Angeles, CA)
- **Manager I - Grievances & Appeals - Member Appeals ** **Location** : This position will work a hybrid model (in office 1-2 days per week). The ideal ... Health PulsePoint locations in California. The **Manager I - Grievances & Appeals ** is responsible for management oversight of receipt, investigation and… more
- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Grievances & Appeals Representative 2 manages client denials and concerns by conducting ... and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 2 performs varied...and other Humana parties. The Grievances & Appeals Representative 2 performs varied activities and moderately complex… more
- Humana (Tallahassee, FL)
- …a part of our caring community and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by conducting ... and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer… more
- VNS Health (Manhattan, NY)
- OverviewManages the day to day activities for staff handling of grievances and appeals for one of the following VNS Health Plans product lines - Managed Long ... to day management of clinical appeals review processes within Appeals & Grievances Department. + Manages the intake, investigation and resolution of member … more
- Elevance Health (Rancho Cordova, CA)
- …or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + ... + 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 clinical… more
- Elevance Health (Los Angeles, CA)
- …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 ... **Nurse Appeals (Quality) - California candidates only** **Location: This...impact:** Responsible for investigating and processing quality of care grievances from members and providers. **Primary duties may include,… more
- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** Appeals and Grievances Representative supports the Operations Department and the Appeals and Grievances team in a ... as well as externally to facilitate timely resolution of all grievances and appeals and ensures compliance with regulations. Additionally, this position is… more
- CDPHP (Albany, NY)
- …This individual will be responsible for tracking, trending and monitoring of appeals , grievances , NYS external review, and making recommendations for change. ... values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process… more
- Elevance Health (Mason, OH)
- …of a relevant Elevance Health location. **Responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond ... to grievances and appeals , manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance.** PRIMARY DUTIES:… more
- Henry Ford Health System (Troy, MI)
- …the prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, ... AND RESPONSIBILITIES:\ + Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from: The Center for… more
- Baylor Scott & White Health (Temple, TX)
- …and resolution of cases; review, research and coordination of complaints, grievances , appeals and reconsiderations consistent with statutory and federal ... OF THE ROLE** + Maintains data entry requirements for all complaints, appeals and grievances . + Builds case files for each complaint, appeal and grievance, and… more
- Humana (Columbus, OH)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director reviews cases of diverse scope and complexity ... PHI / HIPAA information This is a remote position reporting to Grievance and Appeals Director or MD Team Lead **Scheduled Weekly Hours** 40 **Pay Range** The… more
