- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The ... Corporate Medical Director works on problems of diverse scope and complexity...and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation… more
- LA Care Health Plan (Los Angeles, CA)
- …and determination. Performs clinical review of medical records related to grievances and appeals . Responsible for handling member and provider appeals ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN...and management of the A&G Nurse Specialist, RN and/or Medical Director . This position provides assistance to… more
- LA Care Health Plan (Los Angeles, CA)
- … medical necessity reviews. Prepares authorizations, after approval by the Medical Director . When necessary, outreaches to providers, vendors, hospitals, and ... Customer Solution Center Appeals and Grievances Nurse Specialist RN...makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on… more
- VNS Health (Manhattan, NY)
- …staff at all levels including but not limited to, Provider Relations, Claims, Medical Director , third party administrator, pharmacy benefit manager, to achieve ... Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long...minimum of three years' experience in a Grievance and Appeals or related area such as medical … more
- VNS Health (Manhattan, NY)
- … grievances and appeals . Consults with enrollees, providers and the Medical Director , as appropriate. + Provides input and recommendations for design and ... OverviewResolves grievances , appeals and external reviews for...OverviewResolves grievances , appeals and external reviews for VNS Health Plans...a minimum of two years in a grievance and appeals or related area such as medical … more
- Elevance Health (Los Angeles, 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
- Conduent (Hamilton, NJ)
- …reports to the Appeals Supervisor and the Appeals Manager. The Appeals Manager reports to the Director of the Conduent New Jersey Eligibility project. ... individuality is noticed and valued every day. Fair Hearing Appeals Agent $18.50/ Hourly Onsite- Hamilton, NJ Full-time and...for an appeal (Fair Hearings for Plan A and Grievances for Plans B, C, and D) in a… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- Centene Corporation (Atlanta, GA)
- …management programs, integrate physician services, quality assurance, appeals and grievances , and regulatory compliance programs with medical service and ... a fresh perspective on workplace flexibility. **Position Purpose:** The Medical Director works actively to implement and...resolution of member or provider grievances and appeals + Optimizes utilization of medical resources… more
- Elevance Health (Columbus, OH)
- …in partnership with blue cross blue shield plans. Our Government Health Benefits Grievances and Appeals , Enrollment, and Billing Organization is looking to hire ... . Reporting directly to the VP of Grievance & Appeals , this high-performing individual contributor Director will...with health plan operations and back office, Medicare, Medicaid, Grievances & Appeals (G&A), Enrollment, and Billing.… more
- Molina Healthcare (KY)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- BlueCross BlueShield of North Carolina (NC)
- …members + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care + Evaluates authorization requests ... **Job Description** The Medical Director brings a unique set...policy + Care management (utilization management, case management, PA, appeals ) + Healthcare programs (disease management, Moonshots) + Network… 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
- 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
- Highmark Health (Columbus, OH)
- …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
- VNS Health (Manhattan, NY)
- …other evaluative measures to maintain high-quality care standards. + Plans leadership and medical director meetings as stipulated by the State BH contract ... the administration of all BH QM/UM and performance improvement activities, encompassing grievances and appeals , and contributes to various other subcommittees… more
- Fallon Health (Worcester, MA)
- …**Brief Summary of Purpose:** With general direction from the Vice President and Senior Medical Director of Quality and Population Health, the Director of ... as quality improvement, credentialing, member rights, utilization management, including member appeals and grievances to support them in accreditation… more
- State of Colorado (Colorado Springs, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Defined Contribution Plan plus 401K and 457 plans; + Medical and dental health plans; + Short and long...or recommend adjustments to policy and functions or services; INVESTIGATIONS/ GRIEVANCES + Serve as the initial contact and liaison… more
- State of Colorado (CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Defined Benefit Plan or PERA Defined Contribution Plan plus 401K and 457 plans; + Medical and dental health plans; + Short and long term disability coverage; + Paid… 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