- CVS Health (Lansing, MI)
- …based (work at home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part ... * Board Certified in ABMS Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience.… more
- Molina Healthcare (New York, NY)
- … experience. **Required Experience** * 7 years experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 ... for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and… more
- Elevance Health (Atlanta, GA)
- ** Medical Director - Appeals (Primary Care-IM or FM)** **Location: This is a hybrid position. Candidates must live within 50 miles of an Elevance Health ... opportunities. May serve as a resource to staff including Medical Director Associates. May be responsible for...or territory of the United States when conducting utilization review or an appeals consideration and cannot… more
- Humana (Columbus, OH)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... scope and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the… more
- VNS Health (Manhattan, NY)
- …Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + Manages ... staff at all levels including but not limited to, Provider Relations, Claims, Medical Director , third party administrator, pharmacy benefit manager, to achieve… more
- VNS Health (Manhattan, NY)
- …individual grievances and appeals . Consults with enrollees, providers and the Medical Director , as appropriate. + Provides input and recommendations for ... of the plan's fiduciary responsibilities. Prepares records for physician review as needed. + Conducts review of...a minimum of two years in a grievance and appeals or related area such as medical … more
- Elevance Health (Olathe, KS)
- …+ Extrapolates and summarizes medical information for medical director , consultants and other external review . + Prepares recommendations to either ... uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.… more
- Centene Corporation (Olympia, WA)
- …letters are compliant with State and NCQA standards. + Maintain files and logs for all appeals + Coordinate with Medical Director (s) to clarify medical ... State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of… more
- BronxCare Health System (Bronx, NY)
- …in order to prepare a response for submission in appeal. - In absence of Director , will review denial correspondence to determine validity of denial reason and ... preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute...- Reviews and denials notification letters along with the medical records and all pertinent documentation related to the… more
- Intermountain Health (West Valley City, UT)
- …are disputing the medical necessity of the admission. Reports to the Director of Audit and Appeals in the Revenue Integrity Department. ESSENTIAL DUTIES ... **Job Description:** Uses nationally recognized, evidence-based utilization criteria to review medical records and perform clinical assessments for patient… more
- LA Care Health Plan (Los Angeles, CA)
- … medical necessity reviews. Prepares authorizations, after approval by the Medical Director . When necessary, outreaches to providers, vendors, hospitals, and ... Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job...makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on… more
- University of Utah (Salt Lake City, UT)
- …**Requisition Number** PRN39530B **Job Title** Outpatient/Provider Coder Level 3 **Working Title** Medical Appeals Coding Specialist SR **Job Grade** E **FLSA ... of U Health - Academics **Department** 00209 - Univ Medical Billing - Oper **Location** Other **City** Other **Type...summarizing payer concerns and escalating for resolution. 5. Quality Review of team for appropriate coding and documentation (… more
- HCA Healthcare (Nashville, TN)
- …Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Clinical Appeals Team Lead with Parallon you can be a part of an organization ... colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no...our organization. We are looking for an enthusiastic Clinical Appeals Team Lead to help us reach our goals.… more
- Mount Sinai Health System (New York, NY)
- …administrative or medical office experience required , 416 - HSO Appeals Management - MSH, Mount Sinai Hospital **Responsibilities** 1. Serves as an intermediary ... other operational details. This individual typically reports to a manager, director or division head. **Qualifications** + Associates Degree in Secretarial Science… more
- CVS Health (Columbus, OH)
- …client requested coverage determinations or appeals when appropriate. - Medical Directors will participate in inter-rater review activities and other ... Fortune 6 company, has an outstanding opportunity for a Medical Director - Medical Affairs....coverage determinations or appeals when appropriate. - Medical Directors will participate in inter-rater review … more
- San Jose State University (San Jose, CA)
- … Director for Annual Giving Apply now (https://secure.dc4.pageuppeople.com/apply/873/gateway/default.aspx?c=apply&lJobID=543047&lJobSourceTypeID=837&sLanguage=en-us) ... At-Will, Fundraising & Alumni Relations, Full Time Job Summary The Assistant Director for Annual Giving is responsible for developing, implementing, managing, and… more
- City and County of San Francisco (San Francisco, CA)
- …health services, including psychiatric services. The Behavioral Health Services (BHS) Deputy Medical Director of Managed Care provides effective leadership and ... clinical responsibilities with the remaining 70-90% dedicated to Deputy Medical Director responsibilities, which include: + Supports...under Civil Service Rule 111A.35.1. The standard for the review of such appeals is 'abuse of… more
- Humana (Columbus, OH)
- …will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex ... caring community and help us put health first** The Medical Director actively uses their medical...group practice management. + Utilization management experience in a medical management review organization, such as Medicare… more
- CVS Health (Columbus, OH)
- …and providers related to precertification, concurrent review , and appeal request. The medical director is a work-at-home position located anywhere in the US. ... reviews with peer to peer coverage of denials. * Appeals - The medical director ...Medicaid) Experience with managed care (Medicare and Medicaid) utilization review preferred MD or DO; Board certification in an… more
- Evolent Health (Columbus, OH)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Medical Director for the Musculoskeletal department, you will be a key member of ... review process. Responsible for the quality of utilization review determinations, including appeals . + Provides input...questions. + Reviews statistical sample of cases for Field Medical Director audits and makes recommendations into… more