- CVS Health (Salem, OR)
- …home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part C appeals (both ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff *… more
- The Cigna Group (Bloomfield, CT)
- …policies. + Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals . + Support the implementation of new process as needed. + ... limited to:** + Ability to differentiate different types of requests Appeals , Grievances, coverage determination and Organization Determinations in order to ensure… more
- Humana (Columbus, OH)
- …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... established clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be passionate about… more
- Humana (Columbus, OH)
- …us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments ... data requires a case by case consideration of the Medicare rules, Humana policies and medical necessity. The Medical...includes computer based review of moderately complex to complex appeals for coverage for drugs using resources outlined above… more
- VNS Health (Manhattan, NY)
- …state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, ... OverviewResolves grievances, appeals and external reviews for VNS Health Plans...Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully Integrated Dual Advantage (FIDA) and… more
- VNS Health (Manhattan, NY)
- …state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, ... OverviewResolves grievances, appeals and external reviews for one of the...Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Ensures regulatory compliance,… more
- Carle (Urbana, IL)
- …necessity is being challenged. Responsible for enterprise wide outpatient clinical review and appeals on Medicare and Medicaid RAC, PERM, CERTs, etc. audits. ... Outpatient Denial/ Appeals Specialist- RN + Department: Revenue Cycle -...appeals for the Carle enterprise on all outpatient Medicare and Medicaid RAC, PERM, CERT, etc. audits. +… more
- CVS Health (Monroeville, PA)
- …opportunity also provides free parking. **What you will do** + Timely response to Medicare audits and appeals + Research and gather the appropriate documentation ... to form all levels of appeals for Medicare + Third party follow-up associated with the dispensing g of prescription medication via telephone, Internet, and in… more
- Guidehouse (Lewisville, TX)
- …(Manager, Talent Acquisition) at ###_** **Essential Job Functions** + Account Review + Appeals & Denials + Medicare /Medicaid + Insurance Follow-up + Customer ... + 1+ year's medical provider experience working with UB04, appeals & denials. **What Would Be Nice To Have**...Would Be Nice To Have** **:** + Has active Medicare appeal process experience + PC skills in a… more
- UCLA Health (Los Angeles, CA)
- …2 or more years of experience in healthcare operations, managed care, or Medicare Advantage, specifically in handling appeals and grievances preferred * ... guidelines and working with regulatory requirements, preferred * Strong knowledge of Medicare Advantage plans, CMS regulations, and the appeals and grievances… more
- Medical Mutual of Ohio (OH)
- …new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals , Grievances, and Medicare marketing material requirements. . Assists ... new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals , Grievances, and Medicare marketing material requirements. . Assists… more
- US Tech Solutions (RI)
- …volume where needed. **Responsibilities:** + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government ... clients or lines of business and in accordance with Medicare Part D CMS Regulations. + Must apply information...coverage requests. + Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed. +… more
- US Tech Solutions (May, OK)
- …volume where needed. **Responsibilities:** Utilizing multiple software systems to complete Medicare appeals case reviews Meeting or exceeding government mandated ... requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations. Must apply information provided through multiple channels… more
- US Tech Solutions (May, OK)
- …volume where needed. **Responsibilities:** + Utilizing multiple software systems to complete Medicare appeals case reviews + Meeting or exceeding government ... requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations. Must apply information provided through multiple channels… more
- UCLA Health (Los Angeles, CA)
- …skills, particularly in evaluating medical necessity * Thorough understanding of Medicare Advantage regulations, especially related to appeals , grievances, and ... Description As the Appeals & Grievances Nurse, you will play a...of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies. + Identifying… more
- Baptist Memorial (Memphis, TN)
- Summary Medicare / Medicaid Appeals Registered Nurse reviews and evaluates medical documentation to support billing compliance and external regulatory ... of Hospital Revenue Cycle, CPT codes, HCPC codes, modifiers, and the Medicare /Medicaid Appeals Process. Familiarity of billing regulations including federal and… more
- Adecco US, Inc. (Woonsocket, RI)
- … guidance and timelines. + Ensure accuracy of case setup and clinical review of Medicare appeals cases. + Review internal notes or fax requests thoroughly for ... As an RPh Advisor you will be directly supporting Medicare Part D members and providers with requests related...information to decision cases. + Utilize work instructions and Medicare guidelines for accurate case processing. + Comply with… more
- Kelsey-Seybold Clinic (Houston, TX)
- …appropriate timeframes. This position will serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals . The Utilization Review ... based on Texas Department of Insurance (TDI) and or Centers for Medicare and Medicaid (CMS) and healthplan requirements. The Utilization Review Specialist (LVN)… more
- Mohawk Valley Health System (Utica, NY)
- …clinical variability throughout the medical staff. + Assist case managers with Medicare and Medicaid appeals and Administrative Law Judge (ALJ) testimonies. ... prevent denials or carved out days when appropriate. Provide telephonic and written appeals as requested for commercial payors. + Perform reviews and appeals .… more
- Novant Health (Winston Salem, NC)
- …maintains knowledge of processes such as petitioning for guardianship and navigating the Medicare appeals process. + Willingness to cross train between Inpatient ... and Emergency Departments to assist during periods of need. + Communicates individualized plan of care and patient's progress toward goals to all members of the care team including the patient and his/her chosen support system/legal guardian/Care Coordinator.… more