- 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
- Baylor Scott & White Health (Temple, TX)
- …Benefits may vary based on position type and/or level **JOB SUMMARY** **HYBRID POSITION** The Appeals & Grievances ( Medical Auditor) RN conducts reviews of ... to conduct thorough written reviews of appeals , grievances , and reconsiderations using evidence-based medical guidelines...using evidence-based medical guidelines to assist the Medical Director in determining the appropriateness of… more
- Healthfirst (NY)
- …productivity and quality for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case ... + Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization… 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 (Costa Mesa, 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
- 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
- Louisiana Department of State Civil Service (Jackson, LA)
- …Feliciana Medical Complex,Jackson, LA. This position serves at theHUMAN RESOURCE DIRECTOR B for Villa Feliciana Medical Complex, an acute and long ... allocation requirements. Examples of Work This position serves as the Human Resource Director for Villa Feliciana Medical Complex, an acute and long term… more
- Point32Health (MA)
- …are at Point32Health, click here (https://youtu.be/S5I\_HgoecJQ) . **Job Summary** The Medical Director , Clinical reviews will primarily perform utilization ... products, as well as any partner entities at the direction of the Medical Director for Utilization Management. These functions will include prospective,… 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
- Molina Healthcare (Las Cruces, NM)
- …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
- Molina Healthcare (San Bernardino, CA)
- …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
- 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
- Brighton Health Plan Solutions, LLC (Westbury, NY)
- …the standards for acceptable medical care. + Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively ... About The Role The Medical Director will be responsible in...participates in the functioning of the plan's grievance and appeals processes. + Along with the nurse supervisor and… more
- Gwinnett County Public Schools (Suwanee, GA)
- …to, discrimination, Title IX, and requests for accommodations on the basis of a medical impairment. The Director of Employee Relations will assist in providing ... Director of Employee Relations - Office of Employee...resolution in matters related to grievances and appeals , training and development to… more
- CenterLight Health System (Ridgewood, NY)
- …Under the direction of the Chief Medical Officer, the Regional Medical Director is responsible for the professional, organizational, and administrative ... Medical Practice Oversight: + Serve as the Regional Medical Director for the assigned Diagnostic and...clinical review activities. + Support the needs for the appeals and grievances process. + Conduct charts… more
- FlexStaff (New York, NY)
- **Req Number** 146159 FlexStaff FlexStaff is seeking a Regional Medical Director for our client, a non-profit healthcare organization dedicated to providing home ... we encourage you to apply. Overview: As the Regional Medical Director , you will be responsible for...activities. - Conduct chart reviews and assist with the appeals and grievances process. - Participate in… more
- City and County of San Francisco (San Francisco, CA)
- …excellent customer service and for resolving member complaints, grievances , and appeals in a timely manner. The Director communicates and makes presentations ... Organizations. Reporting to the San Francisco Health Service System Board, the Executive Director of SFHSS is the key executive and management leader responsible for… 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