- AmeriHealth Caritas (Philadelphia, PA)
- …. **This position is hybrid in Philadelphia, PA** **Job Summary** The Appeals & Grievance Case Resolution Specialist is responsible for the ... full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, this role conducts case intake, investigation,… more
- Point32Health (FL)
- …Point32Health (https://www.point32health.org/) . **Job Summary** Under the general direction of the Member Appeals and Grievance Supervisor the Appeals and ... for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual… more
- Point32Health (MA)
- …(https://www.point32health.org/) . **Job Summary** SUMMARY Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals and ... for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual… more
- CVS Health (Hartford, CT)
- …AOA Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly ... of this Medical Director role are related to Medicare Appeals :** * Direct daily work on part C ...Appeals :** * Direct daily work on part C appeals (both provider and member/nonparticipating providers) * Provide direct… more
- LA Care Health Plan (Los Angeles, CA)
- …the Clinical Programs. + Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals ... experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment… more
- Elevance Health (FL)
- …by medical directors and consultants; preparing recommendations to uphold or deny appeals ; and ensuring all grievance processes are completed within regulatory ... and/or paralegal experience is strongly desired. + Understanding of the grievance and appeals process is strongly preferred. + Basic knowledge of Medicare and… more
- Humana (Lansing, MI)
- …call center or related customer service experience + 1 - 3 years of grievance and appeals experience + Previous experience processing medical claims + Bilingual ... and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by...review of clinical documentation to determine if an a grievance , appeal or further request is warranted and then… more
- BayCare Health System (Clearwater, FL)
- …information, documentation, and medical records. Triage, plan, and execute intake of Appeals and Grievance submissions. + Keeping track of deadlines, ensuring ... management. + Identify trends or recurring issues in member grievances and appeals and recommend process improvements to prevent future occurrences. + Participate in… more
- Molina Healthcare (Omaha, NE)
- …claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes. * Requests and reviews medical records, notes, ... **Essential Job Duties** * Facilitates comprehensive research and resolution of appeals , disputes, grievances, and/or complaints from Molina members, providers, and… more
- LA Care Health Plan (Los Angeles, CA)
- …RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017 Position… more
- BayCare Health System (Clearwater, FL)
- …review processes including how to analyze and research clinical issues and the appeals and grievance processes. **Minimum Qualifications:** + 2 years of ... **Summary:** + Conducts clinical reviews needed to resolve and process clinical appeals and claims. + Assists with the intake/notification process of cases in… more
- CVS Health (Oklahoma City, OK)
- …of responses from multiple business units. Ensure timely, customer focused response to appeals , complaints and grievance . Identify trends and emerging issues and ... report and recommend solutions. -Research incoming electronic appeals , complaints and grievance to identify if appropriate for unit based upon published business… more
- CVS Health (Sacramento, CA)
- …carrying a modified case load including but not limited to:-Research incoming electronic appeals , complaints and grievance to identify if appropriate for unit ... resource and reroute inappropriate work items that do not meet appeals , complaints and grievance criteria. + Research Standard Plan Design or Certification of… 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 ... other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH Appeals… more
- LA Care Health Plan (Los Angeles, CA)
- …all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters ... inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance /appeal requests, and prepares UM Activity and Weekly Compliance… more
- Fallon Health (Worcester, MA)
- …us on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance ... and Grievances Triage Administrator serves to administer the FH Appeals and Grievance process as outlined in the FH Member Handbook/Evidence of Coverage,… more
- Humana (Washington, DC)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.… more
- Humana (Raleigh, NC)
- …roles include an overview of coding practices and clinical documentation, dispute, grievance , and appeals processes, and outpatient services and equipment, ... member population, or condition type. May also engage in dispute, grievance , and appeals reviews. May participate on project teams or organizational committees.… 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, ... diagnoses and care received. May also engage in disputes and grievance and appeals reviews. May participate on project teams or organizational committees.… more
- Elevance Health (Miami, FL)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... and/or serve as a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations. + Obtain additional state… more
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