- CVS Health (Madison, WI)
- …contract. + Process claim referrals, new claim handoffs, nurse reviews, provider complaints, grievance and appeals via target system. + Assists providers with ... credentialing/re-credentialing and contracting questions and issues. + Assist in compiling claim data for audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal… more
- Highmark Health (Madison, WI)
- …and member requests, received from Medical Management & Policy (MM&P) and Member Grievance Departments. * Responsible for management of Peer to Peer telephone line. ... timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory… more
- Humana (Madison, WI)
- …Review Level of Care for iCare members including follow-up consultation with Grievance and Appeals or Enrollment/Eligibility/Fiscal staff. * Provide appropriate ... Duties and Responsibilities: *Coordinate appointments with members or legal representative to complete Annual and Enrollment redetermination of functional… more