- Baylor Scott & White Health (Temple, TX)
- …may vary based on position type and/or level **JOB SUMMARY** **HYBRID POSITION** The Appeals & Grievances (Medical Auditor) RN conducts reviews of medical ... and plan documentation to conduct thorough written reviews of appeals , grievances , and reconsiderations using evidence-based medical...3 years of relevant work experience + Hold a Registered Nurse license As a health care… 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 ... BSN or MSN degree, required * Current valid California RN license, required * Minimum of 2 years' experience...Advantage setting is highly desired * Experience in handling appeals , grievances , utilization management, or potential quality… more
- LA Care Health Plan (Los Angeles, CA)
- …an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and unrestricted ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US,… 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 ... and performance to ensure quality. + Review and investigate appeals and grievances requests to ensure all...duties as assigned **Minimum Qualifications:** + NYS LPN or RN license. + HS Diploma or GED from an… more
- VNS Health (Manhattan, NY)
- …complexities of healthcare? VNS Health Plans is seeking a dedicated Manager, Grievance and Appeals ( RN )to lead the daily operations of our grievance and ... Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long...+ License and current registration to practice as a registered professional nurse in New York State… more
- Elevance Health (Costa Mesa, CA)
- ** Nurse Appeals - Licensed RN ...and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet ... locations. **Shift:** Monday to Friday from 8:00am-5:00pm PST The ** Nurse Appeals ** is responsible for investigating and...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- CareFirst (Baltimore, MD)
- …people. **QUAIFICATIONS:** **Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse - State Licensure And/or ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor ( RN ) directs and coordinates...data related to the volume and complexity of the appeals and grievances submitted for resolution. **SUPERVISORY… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances , appeals and external reviews for VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully ... or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers....Attends Fair Hearings in person with the Grievance and Appeals ' RN Specialist and presents arguments in… more
- Molina Healthcare (Mesa, AZ)
- …will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals and Grievances experience and a ... them.. **JOB QUALIFICATIONS** **Required Education** Completion of an accredited Registered Nurse ( RN ) Program and an Associate's or bachelor's… more
- Elevance Health (Louisville, KY)
- …the benefits the member carries. **How you will make an Impact:** + The Nurse Appeals is responsible for investigating and processing medical necessity ... **Clinical Review Nurse I** **National Government Services** is a proud...to either uphold or deny appeal. + Ensures that appeals and grievances are resolved timely to… more
- Point32Health (MA)
- …- what you need to perform the job** **EDUCATION, CERTIFICATION AND LICENSURE:** + Registered Nurse with a valid license required + Bachelor of Science in ... of the various roles within Health Care Services, including utilization management and appeals and grievances to develop workflows, job aids, and policies. This… more
- Centers Plan for Healthy Living (Jamaica, NY)
- UM RN 90-27 Sutphin Blvd, Jamaica, NY 11435, USA...the issues appropriately + Have a knowledge of the Appeals and Grievances process + Assists members ... and plans they need for healthy living. JOB SUMMARY: The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who… more
- CVS Health (Frankfort, KY)
- …coverage, and policies. Responsible for the review and resolution of clinical complaints/ grievances and appeals . Interprets data obtained from clinical records ... and ERO eligibility which are required to support the clinical complaints/ grievances and appeals determinations. Pro-actively and consistently applies the… more
- Commonwealth Care Alliance (Boston, MA)
- …lines or medical setting preferred * Prior experience with service authorizations, grievances and appeals , scheduling medical appointments preferred * Ability to ... record, (if applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer.… more
- HCA Healthcare (Rochester, NH)
- …process. Investigates patient rights/issues/referrals. Completes investigation and documentation upon grievances **Education & Experience:** Registered Nurse ... over 156,000 hours volunteering in our communities. As a RN Manager Behavioral Health with Frisbie Memorial Hospital you...obtained within 90 days of employment start date + Registered Nurse + Associate Degree Located in… more
- Sacramento County (Sacramento, CA)
- …Employment Qualifications Minimum Qualifications Possession of a current valid license as a registered nurse and a Nurse Practitioner certification issued by ... Street, Room 2640, Sacramento, CA 95814, telephone: ###. Such appeals must be filed within thirty (30) calendar days...must submit a copy of both my current valid Registered Nurse license AND my Nurse… more
- State of Colorado (Colorado Springs, CO)
- …conflicts, investigates and problem solves internal and external complaints and grievances from staff, youth, family, and other customers. Scheduling of clinic ... to include students and interns. Point of contact for the local schools for RN , NP or PA students. Facilitates regular staff meetings. Data and Reporting: Collects… more