• Clinical Appeals Manager - RN

    CareFirst (Baltimore, MD)
    …process for our membership, and support NCQA accreditation and the Divisional Goals for the Clinical Appeals and Grievance department. We are looking for an ... in addition to the required work experience. **Licenses/Certifications:** + RN - Registered Nurse -... Consultant, Utilization Management, and Government Program experience with Appeals and Grievance , Experience with MCG, InterQual,… more
    CareFirst (11/09/24)
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  • Quality Review Nurse (Remote)

    CareFirst (Baltimore, MD)
    …+ Reviews Clinical Appeals and Grievances documentation written by the clinical appeals nurse and non- clinical supporting team members within ... evaluate clinical quality and procedures within the Clinical Appeals & Grievance Department...addition to the required work experience. **Licenses/Certifications:** + Health Services\ RN - Registered Nurse -… more
    CareFirst (11/15/24)
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  • Manager, Grievance and Appeals

    VNS Health (Manhattan, NY)
    …navigating the complexities of healthcare? VNS Health Plans is seeking a dedicated Manager, Grievance and Appeals ( RN )to lead the daily operations of our ... direct oversight and the day to day management of clinical appeals review processes within Appeals...+ License and current registration to practice as a registered professional nurse in New York State… more
    VNS Health (09/04/24)
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  • Appeals & Grievance Specialist

    Commonwealth Care Alliance (Boston, MA)
    …**Supervision Exercised:** No **Essential Duties & Responsibilities** Processing of Grievances & Appeals : + Responsible for the progress of grievance and appeal ... strict deadlines. + When necessary collaborate with care teams, clinical staff, family members, and other involved in providing...dental, reporting, and member services. + Supports the Senior Appeals & Grievance Coordinator and A/G Coordinator… more
    Commonwealth Care Alliance (11/26/24)
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  • Clinical Appeals Supervisor…

    CareFirst (Baltimore, MD)
    **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor ( RN ) directs and coordinates the accurate implementation of the clinical appeal ... and serves as a resource for associates within the Clinical Appeals and Analysis unit supporting Government...**Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse -… more
    CareFirst (11/09/24)
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  • Manager II Grievances and Appeals

    Elevance Health (Walnut Creek, CA)
    **Manager II Grievance / Appeals ( RN )-California** **Location** : This position will work a hybrid model (remote and office). The ideal candidate will live ... + **Palo Alto** + **Walnut Creek** The **Manager II Grievance / Appeals ** is responsible for management oversight of...clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non- clinical and… more
    Elevance Health (11/06/24)
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  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    …The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse ( RN ) II provides direct assistance to member's with ... Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC...agencies. Good working knowledge of regulatory requirements/standards. Licenses/Certifications Required Registered Nurse ( RN ) - Active,… more
    LA Care Health Plan (11/20/24)
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  • RN / Registered Nurse - Care…

    CareOregon (Medford, OR)
    RN license in the State of Oregon + Minimum 2 year experience as a Registered Nurse ( RN ) in the healthcare industry + Valid driver's license, acceptable ... and must comply with all federal laws. Job Title Registered Nurse - Care Coordinator (Community) Exemption...For Service program benefits). + Report member complaints to Appeals and Grievance team for investigation and… more
    CareOregon (09/27/24)
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  • Nurse Appeals ( RN )

    Elevance Health (Los Angeles, CA)
    ** Nurse Appeals - Licensed RN Nurse ** **Location:** This position will work in a hybrid model (remote and office). Ideal candidates will live in the ... our PulsePoint locations. **Shift:** Monday to Friday from 8:00am-5:00pm PST The ** Nurse Appeals ** is responsible for investigating and processing medical… more
    Elevance Health (11/20/24)
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  • Clinical Appeals Nurse

    CareFirst (Baltimore, MD)
    **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes ... regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes ...**Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse -… more
    CareFirst (11/09/24)
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  • Clinical Appeals Specialist

    CDPHP (Albany, NY)
    …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and ... of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity...external review, and making recommendations for change. QUALIFICATIONS: + Registered Nurse , Physician Assistant or Nurse more
    CDPHP (10/26/24)
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  • Customer Solution Center Appeals

    LA Care Health Plan (Los Angeles, CA)
    Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN II Job Category: Clinical...is primarily responsible for the overall coordination of the Appeals & Grievance (A&G) program for LA… more
    LA Care Health Plan (11/20/24)
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  • Vice President, Clinical Operations…

    CareFirst (Baltimore, MD)
    …requirements. + Appeals , Grievances & Clinical Medical Review: Oversees the Appeals and Grievance function as well as Clinical Medical Review for ... Case Management, Utilization Management including prior authorization, and post service clinical medical review and Appeals & Grievances operational functions… more
    CareFirst (09/06/24)
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  • RN -Utilization Management

    ERP International (Nellis AFB, NV)
    **Overview** ERP International is seeking ** Registered Nurse ( RN ) Utilization Managers** for full-time positions in support of theMike O'Callaghan Military ... admissions, including all eligible beneficiaries, to civilian hospitals and notifies Clinical Nurse Case Manager and Patient Administration Element as… more
    ERP International (11/02/24)
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  • Quality Management Nurse Consultant

    CVS Health (Tallahassee, FL)
    …as well as knowledge of internal systems. **Required Qualifications** + Current unrestricted compact RN license + 3+ years of clinical experience + 2+ years of ... **Position Summary** This is a full-time remote Quality Management Nurse Consultant opportunity. Working schedule is Monday-Friday, 8am-5pm in...hire (Paid for by the company) + Experience working Grievance cases + Appeals experience + Case… more
    CVS Health (11/26/24)
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  • Associate Dean for Faculty Affairs

    University of Connecticut (UConn) (Storrs, CT)
    …and faculty services. + Participates in processes related to faculty counseling, faculty grievance , and appeals related to the SON operations. + Promotes ... and research scholarship with colleagues in the academic and clinical setting. + Ensures that appropriate strategies and policies...(Ph.D., EdD, or equivalent) in Nursing. + Current Connecticut RN license (valid at date of hire). + 3-5… more
    University of Connecticut (UConn) (10/01/24)
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