- R1 RCM (Salt Lake City, UT)
- …platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals Nurse ** , you will help our ... remote, production-driven position. **Here's what you will experience working as a Clinical Appeals Nurse :** + Conduct a detailed review of patient medical… more
- LA Care Health Plan (Los Angeles, CA)
- …with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, ... safety net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II… more
- Elevance Health (Los Angeles, CA)
- ** Nurse Appeals - Licensed RN Nurse.../grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting ... our PulsePoint locations. **Shift:** Monday to Friday from 8:00am-5:00pm PST The ** Nurse Appeals ** is responsible for investigating and processing medical… more
- R1 RCM (Detroit, MI)
- …sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals Supervisor** , you will help support clinicians ... position. **Here's what you will experience working as a Clinical Appeals Supervisor:** + Track and monitor...additional support and engagement. **Required Skills:** + Active Registered Nurse license For this US-based position, the base pay… more
- R1 RCM (Boise, ID)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals and Denials Manager** , you will serve as ... an expert on clinical appeals and denials management. Every day...challenges, and process improvement opportunities. **Required Skills:** + Registered Nurse (active or inactive in good standing and able… 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 ... and thorough review of member and provider complaints, working closely with clinical and administrative teams. + Assessing cases to determine the appropriateness of… 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, ... the safety net required to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing… more
- Centene Corporation (New York, NY)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... **Must have a New York State clinical license.** **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage ... appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting… more
- CVS Health (Hartford, CT)
- …zone of residence. **Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and interprets data obtained from ... active and unrestricted RN licensure in state of residence + 3+ years clinical experience **Preferred Qualifications** + Appeals Experience + Managed Care… more
- CDPHP (Albany, NY)
- …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- VNS Health (Manhattan, NY)
- …Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + ... to day activities for staff handling of grievances and appeals for one of the following VNS Health Plans...quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or… more
- Dayton Children's Hospital (Dayton, OH)
- …insurance denials. This role functions as an internal liaison for members of the clinical team, clinical and operational leadership in the promotion of best ... Completion of accredited BSN program required Certifications + Licensed Registered Nurse in Ohio required + Current professional certification in evidence-based care… more
- Carle (Urbana, IL)
- …resource in outpatient clinical documentation review to establish and manage clinical and prior authorization denial appeals for the Carle enterprise. ... Represents Carle in clinical meetings and writing appeals on outpatient accounts where medical necessity, level of care or prior authorization is questioned.… more
- McLaren Health Care (Bay City, MI)
- …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Baylor Scott & White Health (Temple, TX)
- …expedited and external case reviews, and prepares final case submissions. + Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for ... **JOB SUMMARY** Hybrid position - Temple, TX The Appeals and Grievance Specialist performs reviews, within operational...within operational aspects, of the member and provider complaints, appeals and grievance cases for products for all lines… more
- Adecco US, Inc. (Los Angeles, CA)
- Adecco Healthcare & Life Sciences is hiring an Appeals Pharmacist. This role is remote / work from home. Please read below and apply with an updated resume for ... to 5pm PST **Pay:** $70.00 to $73.00 an hour **Responsibilities of the Appeals Pharmacist:** . Collaborates with the coordinators and nurses to process referrals,… more
- Select Medical (Los Angeles, CA)
- …Century City / Los Angeles, CA Case Manager (CM) - Full Time (on-site) Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) **Pay Rate: $50 - $58.65 ... process. The primary job functions in Case Management include: Clinical Interventions/Discharge and Care Planning Management; Fiscal Management; and Payer/Referral… more
- Johns Hopkins University (Baltimore, MD)
- …in the Johns Hopkins system. + Experience with EPIC. Classified Title: Clinical Nurse Role/Level/Range: ACRP/03/ME Starting Salary Range: $64,600 - $113,300 ... The Department of Medicine is seeking a **_Clinical Nurse_** to coordinate clinical activities and provide nursing case management services to patients across… more
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