- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager , Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances ... net required to achieve that purpose. Job Summary The Manager , Appeals & Grievances (A&G)...appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public… more
- Fallon Health (Worcester, MA)
- …other applicable regulatory requirements and member and provider expectations. The FH Appeals and Grievances Triage Administrator serves to administer the FH ... standards. The Triage Administrator is responsible for triaging and assigning all incoming appeals and grievances addressed to the Member Appeals &… more
- Elevance Health (FL)
- …providers, and regulatory entities, and serves as a subject matter expert for appeals , grievances , and quality of care issues. + Key responsibilities: serves ... **Nurse Appeals - Litigation & Legal Support** **In Office...is strongly preferred. + Basic knowledge of Medicare and Medicaid guidelines is preferred. + Ability to, and comfortability… 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 ... the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid , and PACE (Program of All-Inclusive Care for the...assigning all incoming appeals and grievances… more
- Sanford Health (Rapid City, SD)
- …and interaction with payers. Additional duties include management of medical denials, appeals , and grievances . Understand and provide insight into evaluating ... Details** Join our team as a Utilization Review and Case Management Manager and lead a high-impact, data-driven program that elevates patient outcomes while… more
- Healthfirst (Enfield, NY)
- …Claims departments. Clearly communicate resolutions and progress to the Providers. + Assist Appeals and Grievances (A&G) department by acting as liaison between ... of Ancillary Providers for all lines of Healthfirst's business (such as Medicaid , CHP, Medicare, and Commercial). + Monitor and audit contracted ancillary providers… more
- Molina Healthcare (AZ)
- …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
- Elevance Health (San Juan, PR)
- …inquiries and support other lower level pharm techs. + Provides resolution to grievances and appeals issues. + Responds to inquiries from physicians, sales ... authorization requests from physicians' offices and ensures compliance with all Medicaid , Commercial, and Medicare requirements. + Informs relevant parties of all… more
- Elevance Health (Indianapolis, IN)
- …relevant parties of all prior authorization determinations. + Provides resolution to grievances and appeals issues. + Responds to inquiries from physicians, ... is a clinical pharmacy call center that services Medicare, Medicaid , and the Commercial member populations. The members we...Strategy. Unless specified as primarily virtual by the hiring manager , associates are required to work at an Elevance… more
- Healthfirst (NY)
- …including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions + Partner ... and deep familiarity of health plans such as Medicare, Medicaid and//or Managed Long-Term Care Plan (MLTCP). + Demonstrated...for executive-level decision-making + Experience working as a case manager for a long-term care programs such as PACE,… more
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