- Baylor Scott & White Health (Temple, TX)
- …vary based on position type and/or level **JOB SUMMARY** **HYBRID POSITION** The Appeals & Grievances (Medical Auditor) RN conducts reviews of medical records, ... and plan documentation to conduct thorough written reviews of appeals , grievances , and reconsiderations using evidence-based medical guidelines to assist the… more
- UCLA Health (Los Angeles, CA)
- Description As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances . ... or Medicare Advantage setting is highly desired * Experience in handling appeals , grievances , utilization management, or potential quality issues * Knowledge… more
- LA Care Health Plan (Los Angeles, CA)
- Lead Customer Solution Center Appeals and Grievances Job Category: Administrative, HR, Business Professionals Department: CSC Appeals & Grievances ... achieve that purpose. Job Summary The Lead of Customer Solution Center Appeals and Grievances is responsible for assisting with the development of a successful… more
- Point32Health (Canton, MA)
- …and Federal regulations, for assisting with all operational aspects of the Appeals and Grievances assignment process for Point32Health. Responsibilities include, ... department processes as requested from management; note trends in Appeals and Grievances and notify supervisors of their findings and ensuring professional… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Appeals and Grievances Clinical Operations RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... required to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day… 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
- Molina Healthcare (Columbus, OH)
- …+ Responsible for the comprehensive research and resolution of the appeals , dispute, grievances , and/or complaints from Molina members, providers ... that internal and/or regulatory timelines are met. + Research claims appeals and grievances using support systems to determine appeal and grievance outcomes. +… more
- Generac Power Systems (Waukesha, WI)
- …technology solutions company, we continue to push new boundaries. **Job Summary:** 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
- Healthfirst (NY)
- …+ Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization ... management/case management. + Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines + Ability to work independently on several computer applications such as Microsoft Word… more
- Healthfirst (NY)
- **Duties and Responsibilities:** + Conduct quality audits of A&G items including grievances , pre-service appeals , and post service appeals utilizing ... processes and performance to ensure quality. + Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Training Specialist II Job Category: Customer Service Department: CSC Training & Performance Location: Los ... to achieve that purpose. Job Summary The Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is primarily responsible for the overall… more
- Molina Healthcare (WI)
- …**Knowledge/Skills/Abilities** + Reviews, classifies, researches, and resolves member complaints ( grievances and/or appeals ) and communicates resolution in ... and documents Medicaid and Medicare Advantage denial determinations for reconsiderations/ appeals in a thorough, professional and expedient manner. May include… more
- VNS Health (Manhattan, NY)
- …opportunity to: * Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare ... our high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. * Data-Driven Decisions: Maintain the integrity of… more
- Elevance Health (Costa Mesa, 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 (Atlanta, GA)
- …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
- Point32Health (TX)
- …responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for ... to organize, plan and implement the functions of Member Appeals and Grievances , maintain timelines and turnaround times to meet multiple requirements/regulations… more
- Medical Mutual of Ohio (Brooklyn, OH)
- …appeal/grievance requests and electronic inquiries in order to identify and classify appeals and grievances as outlined in policies and procedures. Using ... responses on applicable systems. . Serves as a resource/training for appeals and grievances unit staff and as a resource for internal/external questions related… more
- CareFirst (Baltimore, MD)
- …data and data related to the volume and complexity of the appeals and grievances submitted for resolution. **QUALIFICATIONS:** **Education Level:** High ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation...serves as a resource for associates within the Clinical Appeals and Analysis unit. We are looking for an… more
- Henry Ford Health System (Troy, MI)
- …for the prompt and thorough investigation of medical and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare ... 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
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