- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The Corporate ... diverse scope and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the… more
- Healthfirst (NY)
- …+ Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization ... (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines + Ability to work independently...such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess). Experience… more
- VNS Health (Manhattan, NY)
- …exciting opportunity to: * Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), ... high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. *...Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Part D, or Select Health to… more
- Centene Corporation (Jefferson City, MO)
- …interpretation of proposed and promulgated laws, provides counsel with regards to grievances , appeals and provider dispute resolution, risk adjustment, benefits, ... Prescription Drug Plans and an understanding of risk adjustment, Stars, broker/sales, grievances and appeals , utilization management, dual eligible special needs… more
- Robert Half Accountemps (Durham, NC)
- …team. This role is situated within the healthcare industry, specifically dealing with Medicare Advantage Member appeals from providers. The workplace is based in ... standards. Responsibilities: * Analyze and resolve confidential and sensitive appeals , grievances , and coverage/organization determinations from various… more
- CareOregon (Portland, OR)
- …of subcontracted entities, fraud waste and abuse prevention planning and investigations, grievances , hearings and appeals , corporate risk assessment and ... tracking, documentation, collection, file maintenance, reporting and resolution of the hearings, appeals and grievances processes. + Develop and lead Health… more
- BlueCross BlueShield of North Carolina (NC)
- …healthcare services provided to Plan members + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care + ... pharmacy utilization and effective resource management + Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements + Reviews quality… more
- Henry Ford Health System (Troy, MI)
- …testing. + Comprehensive knowledge of Medicare rules and regulations, including appeals , grievances , the annual election period, Medicare Advantage ... staffing and coordination of activities as they pertain to divisional and corporate initiatives, strategies and objectives. + Use data analytics to drive performance… more
- CareFirst (Baltimore, MD)
- …validation, new plan implementations, Prescription Drug Event and Coverage Determination, Appeals and Grievances analysis, policies, and procedures. Work with ... **Resp & Qualifications** **PURPOSE:** Responsible for all key aspects of Medicare Pharmacy operations including formulary and benefits administration and testing,… more