- LA Care Health Plan (Los Angeles, CA)
- Lead Customer Solution Center Appeals and Grievances Job Category: Administrative, HR, Business Professionals Department: CSC Appeals & Grievances Location: Los ... that purpose. Job Summary The Lead of Customer Solution Center Appeals and Grievances is responsible for assisting with the development of a successful and cohesive… 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 ... to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical… more
- Elevance Health (Columbus, OH)
- …PST The **Manager II Grievance/Appeals** is responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to ... grievances and appeals, manages inventory and production levels, and...decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of… 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 ... Advantage setting is highly desired * Experience in handling appeals, grievances , utilization management, or potential quality issues * Knowledge of Medicare… more
- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a ... and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support… more
- Molina Healthcare (Columbus, OH)
- …for the comprehensive research and resolution of the appeals, dispute, grievances , and/or complaints from Molina members, providers and related outside agencies ... internal and/or regulatory timelines are met. + Research claims appeals and grievances using support systems to determine appeal and grievance outcomes. + Requests… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Specialist II will receive, investigate and resolve member and provider… more
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA-Appeals & Grievances Advisor, Appeals and Grievances Program Non-member facing Non-Applicable EEO is The Law Equal Opportunity Employer ... Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG… more
- Generac Power Systems (Waukesha, WI)
- …company, we continue to push new boundaries. **Job Summary:** The **Appeals and Grievances Specialist** is a critical team player who is responsible for providing ... with some guidance from leadership and higher-level Appeals and Grievances Specialists. **Job Responsibilities:** Case Resolution + Handles escalated calls/cases… more
- Healthfirst (NY)
- …+ Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization management/case management. + ... Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines + Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as… more
- Humana (Columbus, OH)
- …+ MD or DO degree + A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of ... assignment + Board Certified in an approved ABMS Medical Specialty + Excellent communication skills + 5 years of established clinical experience + Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products + Possess analysis… more
- Sutter Health (Modesto, CA)
- …: **EDUCATION:** + _Equivalent experience will be accepted in lieu of the required degree or diploma._ + Bachelor's: degree in Business Administration, Nursing, ... Social Work, or other health care related field **TYPICAL EXPERIENCE:** + 2 years recent relevant experience **SKILLS AND KNOWLEDGE:** + Oral and written communication skills. must demonstrate writing skills including the ability to synthesize the facts of an… more
- VNS Health (Manhattan, NY)
- …to: * Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare Advantage ... meet our high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. * Data-Driven Decisions: Maintain the integrity… more
- Virginia Mason Franciscan Health (Tacoma, WA)
- …responsible for coordinating and tracking the timely resolution of customer complaints/ grievances for the assigned Virginia Mason Franciscan Health (VMFH) entity in ... parties and the appropriate department management to facilitate resolution of grievances , complaints and/or other issues concerning the quality of care and… more
- Texas Health Resources (Bedford, TX)
- …**Responsible for management of hospital's response to patient complaints and grievances .** Coordinates review of complaints and grievances including researching ... response based on CMS guidelines and hospital policy. Receives complaints and/or grievances directly from patients or others on the patient's behalf by multiple… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances , appeals and external reviews for VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully ... grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and… more
- Tufts Medicine (Boston, MA)
- …**Under general supervision, manages, investigates, and responds to patient complaints and grievances for both hospital and clinic patients. Highly visible on all ... patient satisfaction. Works closely with risk management department on sever grievances involving litigation. Assures the organization remains compliant with the CMS… more
- Elevance Health (Harrisburg, PA)
- …Department that reviews analyzes and processes non-complex pre-service and post-service grievances and appeals requests from customer types (ie member, provider, ... of service, and quality of care issues to include executive and regulatory grievances . **How you will make an impact:** + Reviews analyzes, and processes non-complex… more
- Lawrence General Hospital (Methuen, MA)
- …patient experience, responsible for the management of patient complaints and grievances , patient relations and compliance with accreditation standards related to ... and regulatory agency requirements related to management of patient complaints & grievances . Regulatory and accreditation agencies include but are not limited to:… more
- Medical Mutual of Ohio (OH)
- …updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals, Grievances , and Medicare marketing material requirements. . Assists in internal ... in the research and review of Part D and Part B inquiries, grievances , and CTMs, updating tracking documents, audit research items, and marketing material reviews.… more
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