- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... and serves as a resource for associates within the Clinical Appeals and Analysis unit. We are...appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and… more
- R1 RCM (Salt Lake City, UT)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals and Denials Manager** , you will serve as ... an expert on clinical appeals and denials management. Every day...& support verticals to ensure optimization of workflow + Review and analyze denial reports, identify trends and root… more
- R1 RCM (Detroit, MI)
- …you will help support clinicians who conduct a comprehensive review of clinical denials and formulate appeals based on clinical documentation, ... position. **Here's what you will experience working as a Clinical Appeals Supervisor:** + Track and monitor...outcomes. + Assess the viability of cases for external review or escalation, as well as make final determinations… more
- CareFirst (Baltimore, MD)
- …for our membership, and support NCQA accreditation and the Divisional Goals for the Clinical Appeals and Grievance department. We are looking for an experienced ... including (EGWP, DSNP, MAPD). Ensures quality management of the clinical appeal process to reduce the risk of State...with dynamic goals resulting in the full and fair review of appeals and designed to achieve… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...continued stay using evidence from the medical record and clinical review tools, as well as input… more
- St. Luke's Health System (Twin Falls, ID)
- …a great place to work. **What You Can Expect:** Under limited supervision, the Clinical Appeals Specialist 2, is responsible for managing client medical denials ... by conducting a comprehensive analytic review of clinical documentation to determine if...provide and maintain a single reporting location that reflects clinical denials and appeals activity. + Recommends… more
- Adecco US, Inc. (Minneapolis, MN)
- Adecco Healthcare & Life Sciences is hiring a **remote Clinical Appeals Reviewers** ! This role is remote but may need to go to the office in Ontario, CA from ... time to time. Please read below and apply with an updated resume for consideration: **Type:** Three-month contract, opportunity for extension or full-time offer **Schedule:** Monday through Friday, 8AM to 4:30PM **Pay:** $24 to $26.30an hour… more
- R1 RCM (Salt Lake City, UT)
- …AI, intelligent automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse** , you will help review and interpret medical records ... remote production-drive position. **Here's what you will experience working as a Clinical Coding Appeals Nurse:** + Review and interpret medical records to… more
- Northwell Health (Melville, NY)
- …stay. Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately ... certifications as needed. + Prior experience in Case Management, Utilization Review , and Appeals /Denials, highly preferred. *Additional Salary Detail The… more
- Evolent (Columbus, OH)
- …processed appeals . **Qualifications Required and Preferred** : + 1-3 years' experience in clinical Appeals Review and is an LPN - Required and Preferred. ... and client policies and procedures while complying with timeliness guidelines. Our clinical nurse reviewer team values collaboration, continuous learning, and a… more
- Community Health Systems (Franklin, TN)
- …Other duties may be assigned. + File medical necessity and level of care appeals using InterQual and CMS guidelines as needed. + Monitor clinical appeal ... guidance and feedback to related departments as needed. + Track and manage clinical denials using current tools (manuals, training programs). + Identify patterns and… more
- VNS Health (Manhattan, NY)
- …You Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. ... Health Plans is seeking a dedicated Manager, Grievance and Appeals (RN)to lead the daily operations of our grievance...quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of… more
- CVS Health (Hartford, CT)
- …Monday-Friday 8a-5p in time zone of residence. **Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and ... active and unrestricted RN licensure in state of residence + 3+ years clinical experience **Preferred Qualifications** + Appeals Experience + Managed Care… more
- Healthfirst (NY)
- …degree + Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case ... and Responsibilities: + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity,… more
- Catholic Health Services (Melville, NY)
- … clinical expertise/reference for specialty services as needed to adequately prepare clinical review and/or appeal. | Demonstrates aptitude and skill in ... Top Workplace! Job Details Position Summary: The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews...care to MCC in response to physician order, or review of updated clinical information | Acts… more
- UCLA Health (Los Angeles, CA)
- …maintaining updated records in various systems + Review claim denials for clinical issues, prepare appeals , and manage each case's resolution process + ... world-class healthcare organization by ensuring compliance in regulatory audits and appeals . Leverage your expertise to support UCLA Health's commitment to accuracy… more
- Martin's Point Health Care (Portland, ME)
- …and third-party administrators + Prepares case files on clinical member and provider appeals for review by clinical team members + Prepares and sends ... Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals , non-participating provider pre- and post-service appeals , and participating… more
- BrightSpring Health Services (Louisville, KY)
- …management. This position will also support detailed level reporting and analytics, clinical appeals , root cause analysis, and address identified trends in ... as well as Support staff managing all areas of clinical claim pre and post audit, appeals ...per applicable home health regulations for submission for pre-claim review process of Review Choice Demonstration.* Audits… more
- Robert Half Accountemps (Durham, NC)
- …medical policies and collaborate with Medical Directors for decisions regarding clinical appeals /grievances * Ensure quality, efficiency, and timeliness in ... within the healthcare industry, specifically dealing with Medicare Advantage Member appeals from providers. The workplace is based in Durham, North Carolina,… more
- Hartford HealthCare (Farmington, CT)
- …works collaboratively with appropriate teams to prevent future denial. . Coordinates clinical appeals process and participates in compliance investigations as ... works with others as needed to determine the appropriate course of denial appeals . . Maintains accurate, clear, timely documentation related to denied cases. .… more