- Harbor Health Services, Inc. (Mattapan, MA)
- …knowledge of all aspects of managed care medical management including UM/CM, Grievance and Appeals , inpatient and outpatient services, medical policy, and ... and cares for more than 580 participants. We are currently seeking a Director of Utilization Management & Quality Programs. Harbor Health offers an excellent,… more
- Sanford Health (Sioux Falls, SD)
- …strategic oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, ... adherence to all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end appeals and… more
- CVS Health (Hartford, CT)
- …remote based (work at home) based anywhere in the US. **Responsibilities of this Medical Director role are related to Medicare Appeals :** * Direct daily work on ... AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- Elevance Health (Tampa, FL)
- …+ Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved ... **Nurse Appeals ** **Hybrid 1:** This role requires associates to...timely to meet regulatory timeframes. + Documents and logs appeal/ grievance information on relevant tracking systems and mainframe systems.… more
- Elevance Health (Columbus, OH)
- …+ Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved ... **Nurse Appeals RN** **Location** : Ohio-Cincinnati, Columbus, Mason, or...timely to meet regulatory timeframes. + Documents and logs appeal/ grievance information on relevant tracking systems and mainframe systems.… more
- CenterWell (Boston, MA)
- …of the role includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director , Primary Care relies on medical background and reviews...member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Humana (Providence, RI)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews preauthorization requests...member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Humana (Raleigh, NC)
- …roles include an overview of coding practices and clinical documentation, dispute, grievance , and appeals processes, and outpatient services and equipment, ... community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement...population, or condition type. May also engage in dispute, grievance , and appeals reviews. May participate on… more
- Humana (Carson City, NV)
- …Some roles include an overview of coding practices and clinical documentation, dispute/ grievance and appeals processes, and outpatient services and equipment, ... community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement...and care received. May also engage in disputes and grievance and appeals reviews. May participate on… more
- City of New York (New York, NY)
- …planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy ... arise with CFB employees. - Serve as the CFB's grievance representative and administer the contractual grievance ...process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before the Office… more
- Fallon Health (Worcester, MA)
- …us on Facebook, Twitter and LinkedIn. **Brief summary or purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance ... standards, other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH… 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
- Elevance Health (Miami, FL)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Medical Director ** **Medical Oncology** **Carelon Medical Benefit Management** **Virtual**...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more
- Humana (Indianapolis, IN)
- …not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic ... a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director … 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
- Elevance Health (Mason, OH)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Associate Medical Director ** **Carelon Medical Benefits Management** **Radiology Benefit Management/Utilization Review** **Virtual:** This role… more
- AmeriHealth Caritas (Washington, DC)
- **Job Responsibilities** The Director Operations (Healthy DC Plan) reports to the Market President, with oversight of operation services delivered by the ;Healthy DC ... Plan and all relevant federal, state, and local regulatory requirements. The Director Operations Healthy DC Plan is accountable for ensuring the plan's operating… more
- Gwinnett County Public Schools (Suwanee, GA)
- Director of District Title IX Compliance - Division of Human Resources JobID: 99797 + Position Type: Administrative/Managerial/ Dir District Title IX Comp + Date ... to identify and address systemic problems.ESSENTIAL JOB DUTIES1. Lead all Title IX appeals processes for the district. 2. Ensure GCPS policy aligns with government… more
- Transdev (Dorchester, MA)
- …The Labor Relations Manager provides support to the General Manager and Director of Human Resources on labor relations projects, priorities and issues. This ... + Research, compile, and prepare data for use in grievance hearings, arbitration proceedings, labor/management initiatives, collective bargaining negotiations, and… more
- Johns Hopkins University (Baltimore, MD)
- …Office of Employee and Labor Relations. This position will report, to the Director of Employee Relations and Labor Relations (ER/LR). This position will provide a ... actions and make sound recommendations to management. + Manage the grievance process, including fact finding, reviewing evidence, serving as hearing officer,… more
