- Sanford Health (Sioux Falls, SD)
- …governing appeals and grievance resolution. Lead and manage the end-to-end appeals and grievances process for all product lines, ensuring compliance with ... Oversee the intake, review, resolution, and documentation of all appeals , complaints, and grievances to meet regulatory...and documentation of all appeals , complaints, and grievances to meet regulatory and operational standards. Ensure all… more
- Elevance Health (Tampa, FL)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
- Elevance Health (Columbus, OH)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
- Dignity Health (Rancho Cordova, CA)
- **Job Summary and Responsibilities** The Appeals and Grievances LVN is a critical role responsible for managing and resolving all medical necessity appeal ... and maintaining patient confidentiality (HIPAA) are also essential. Ultimately, the Appeals and Grievances Nurse monitors denial trends, recommends corrective… more
- Elevance Health (Indianapolis, IN)
- …to Medical Director for final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external review. + Research to...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage review, member… more
- Volunteers of America Upstate New York (Rochester, NY)
- …standards. Resident Services & Accountability - Assist with escalated discipline, grievances , appeals , and behavioral interventions. - Support intake/orientation ... Travel Percentage Up to 25% Description Position Title: Assistant Director - RRC Grade: Category : Exempt Reports to:... - RRC Grade: Category : Exempt Reports to: Director Salary : $65,000 Our Mission: To enable people… more
- Point32Health (MA)
- …are at Point32Health (https://www.point32health.org/) . **Job Summary** The Medical Director , Clinical reviews will primarily perform utilization management and ... well as any partner entities at the direction of the Medical Director for Utilization Management. These functions will include prospective, concurrent, and… more
- AmeriHealth Caritas (Washington, DC)
- …Management, Program Integrity, Risk Adjustment, Provider Resolution Team, Provider Appeal and Grievances , Member Appeals and Grievances , Network adequacy and ... **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the...all relevant federal, state, and local regulatory requirements. The Director Operations Healthy DC Plan is accountable for ensuring… more
- Molina Healthcare (Tampa, FL)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- City of New York (New York, NY)
- …and administer the contractual grievance process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before ... planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy… more
- Herkimer County Community College (Herkimer, NY)
- …and serve as the lead administrator for negotiations with bargaining units. Facilitate grievances and employee appeals related to working conditions and contract ... Job Description: Herkimer College is seeking qualified applicants for a full-time Director of Human Resources. This position provides overall coordination of human… more
- Sioux City Community School District (Sioux City, IA)
- Job Details Job ID: 5460842 Job Description EXECUTIVE SUMMARY The Executive Director supports the mission of the Sioux City Community School District by fostering ... and develop communication for donor stewardship including thank you letters, appeals , newsletters, social media, impact reports, and other communications. + Plan… more
- Dignity Health (Bakersfield, CA)
- … of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related duties. **Job Requirements** ... primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing and driving… more
- Fallon Health (Worcester, MA)
- …of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and ... assigning all incoming appeals and grievances...for additional clerical/administrative responsibilities at the discretion of the Director or Manager. * Providing administrative assistance in support… more
- UCLA Health (Los Angeles, CA)
- …+ Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Partner with clinical and operational ... Plan is looking for a dedicated and forward-thinking Medical Director , Clinical Operations to help shape the future of...key leadership role, you'll work closely with the Medical Director , Department of Health Services and play a vital… more
- UPMC (Pittsburgh, PA)
- …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization Management is responsible… more
- Washington County Mental Health Services (Barre, VT)
- …Identify and mitigate compliance and quality risks through proactive measures, manage Grievances and Appeals processes, and conduct routine assessments of ... Senior Director of Quality Assurance and Compliance Washington County...County Mental Health Services is seeking an experienced Senior Director of Quality Assurance and Compliance to join our… more
- Molina Healthcare (Fort Worth, TX)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse… more
- Highmark Health (Harrisburg, PA)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
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