- VNS Health (Manhattan, NY)
- …and 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
- Humana (Columbus, OH)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director reviews cases of diverse scope ... and complexity ranging from moderate to substantial. The Corporate Medical Director reviews medical necessity...This is a remote position reporting to Grievance and Appeals Director or MD Team Lead **Scheduled… 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 ... the day to day activities for staff handling of grievances and appeals for one of the...minimum of three years' experience in a Grievance and Appeals or related area such as medical … more
- Elevance Health (Rancho Cordova, 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
- Elevance Health (Los Angeles, CA)
- …+ Prepares recommendations to assign appropriate level or forwards to Medical Director for decision. + Ensures that grievances are resolved timely to meet ... retrospective medical records. + 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
- Molina Healthcare (Starkville, MS)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... medical and clinical staff. + Part Time Perinatal Medical Director , Based in MS **Job Duties**...+ Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the… 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
- 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, ... Clinical Director - Summit Youth Services Center in Golden...& group contact; Management of delinquent behavior; Liaison to medical and psychiatric services; Formal supervision for BH staff;… more
- Elevance Health (Indianapolis, IN)
- …desired for this role!** **The Strategy Director ** supports Government Business Grievances & Appeals and Government Business Enrollment Billing. In this ... is strongly preferred. + Business knowledge in Government Health Benefits to include Grievances & Appeals and/or Enrollment Billing preferred. + Master's degree… 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
- UCLA Health (Los Angeles, CA)
- …utilization and case management activities to drive efficiency and quality + Oversee appeals , grievances , and potential quality issues (PQI) + Develop and ... at New Century Health Plan. Reporting to the Chief Medical Officer, you will play a pivotal role in...with: + MD or DO degree from an accredited medical school + Board certification in a primary care… more
- Elevance Health (Overland Park, KS)
- …will make an impact:** + Reviews or provides oversight for dental quality of care grievances and appeals . + Reviews or provides oversight as needed for dental ... **State Dental Director ** **Location: This position will work a hybrid...bonus programs (unless covered by a collective bargaining agreement), medical , dental, vision, short and long term disability benefits,… 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
- Stanford Health Care (Palo Alto, CA)
- …stay review, retrospective review of care, medical claims review, addressing denials/ appeals and grievances effectively and timely, and compliance with payer ... improvements. + Directs the utilization management, concurrent review, prior authorizations medical claims review, appeals and grievances functions.… 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 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
- The Cigna Group (Bloomfield, CT)
- …well as research and provide a written detailed clinical summary for the Plan Medical Director . + Determine whether additional pre service, appeal or grievance ... in Medicare Part C + Ability to differentiate different types of requests Appeals , Grievances , coverage determination and Organization Determinations in order to… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Contribution Plan, plus optional 401K and 457 plans + Medical and dental health plans (http://www.colorado.gov/cs/Satellite/DPA-DHR/DHR/1236690495481) + Paid life… more
- State of Colorado (Lakewood, CO)
- …hygiene practice. + Ensures that youth are provided confidential access to grievances , medical assistance and mental health assistance as needed/requested ... Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes,… more
