- R1 RCM (Salt Lake City, UT)
- …analytics, AI, intelligent automation, and workflow orchestration. As our **Clinical Coding Appeals Nurse ** , you will help review and interpret medical ... position. **Here's what you will experience working as a Clinical Coding Appeals Nurse :** + Review and interpret medical records to appeal denied and underpaid… 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. You ... or Medicare Advantage setting is highly desired * Experience in handling appeals , grievances, utilization management, or potential quality issues * Knowledge of… more
- Elevance Health (Costa Mesa, CA)
- ** Nurse Appeals - Licensed RN Nurse ** **Location:** This position will work in a hybrid model (remote and office). Ideal candidates will live in the state of ... our PulsePoint locations. **Shift:** Monday to Friday from 8:00am-5:00pm PST The ** Nurse Appeals ** is responsible for investigating and processing medical… more
- CVS Health (Hartford, CT)
- …**Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and interprets data obtained from clinical records to ... as required. This position may support UM, MPO, Coding, or Behavioral Health appeals . **Required Qualifications** + Must have active and unrestricted RN licensure in… more
- Evolent (Columbus, OH)
- …Join a mission with a company behind it. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a meaningful impact ... as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to… more
- CareFirst (Baltimore, MD)
- …as needed. Reviews, researches problematic correspondence and works on special projects with Appeals Nurse or Management. + Interacts regularly with and responds ... **Resp & Qualifications** **PURPOSE:** The Appeals Specialist II will be responsible for the...II will be responsible for the initial analysis of appeals correspondence, and determination of next steps, with minimal… more
- Northwell Health (Melville, NY)
- …current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness ... of job entry date. + Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. + Prior… 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 member...appeals requests from beneficiaries and providers + Conducts investigations and… more
- Baptist Memorial (Memphis, TN)
- Summary Medicare / Medicaid Appeals Registered Nurse reviews and evaluates medical documentation to support billing compliance and external regulatory ... Responsibilities + Abstracts pertinent information from the medical record to create appeals for cases denied by governmental payors. + Educates department staff to… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for members ... serves as a resource for associates within the Clinical Appeals and Analysis unit. We are looking for an...3 years supervisory experience. **Licenses/Certifications** + RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon… 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 appeals ... * Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare Advantage (MA), or… more
- CareFirst (Baltimore, MD)
- …and support NCQA accreditation and the Divisional Goals for the Clinical Appeals and Grievance department. We are looking for an experienced people leader ... with dynamic goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance departmental capabilities. Accountable… more
- R1 RCM (Detroit, MI)
- …analytics, AI, intelligent automation, and workflow orchestration. As our **Clinical Appeals Supervisor** , you will help support clinicians who conduct a ... comprehensive review of clinical denials and formulate appeals based on clinical documentation, evidence-based medical necessity criteria, physician documentation,… 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, 90017 ... safety net required to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the… more
- 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 Medical… more
- BronxCare Health System (Bronx, NY)
- …the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to ... identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and… more
- Baylor Scott & White Health (Temple, TX)
- **JOB SUMMARY** Hybrid position - Temple, TX The Appeals and Grievance Specialist performs reviews, within operational aspects, of the member and provider ... complaints, appeals and grievance cases for products for all lines...case submissions. + Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for handling where required.… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES & ESSENTIAL JOB...health plan. Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California, Active BLS -… more
- Molina Healthcare (Mesa, AZ)
- …our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals and Grievances experience and a clinical background. ... and production levels are maintained + Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management… more
- Brighton Health Plan Solutions, LLC (Westbury, NY)
- …of care and actively participates in the functioning of the plan's grievance and appeals processes. + Along with the nurse supervisor and manager identify ... care to ensure quality, cost-efficiency and continuity of care; Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC,… more
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