- CVS Health (Providence, RI)
- …in the US.** Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on part C appeals (both provider and ... policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal...Recognized Specialty **Preferred Qualifications** Medical Management - Medicare Complaints, Grievance & Appeals experience. *… more
- Humana (Providence, RI)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Humana (Providence, RI)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- Humana (Providence, RI)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes reviewing of all… more
- Humana (Providence, RI)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- CVS Health (Providence, RI)
- …health care more personal, convenient and affordable. **Job Purpose and Summary:** The Dental Director - Medicare Appeals is an individual contributor who ... processes, including credentialing, site assessments, peer review, complaints, grievances and appeals (CGA) + Consults and lends expertise to other internal and… more
- Evolent Health (Providence, RI)
- …recorded in a timely and accurate manner. + May assist the Senior Medical Director in research activities/questions related to the Utilization Management ... request and provides clinical rationale for standard and expedited appeals . + Utilizes medical /clinical review guidelines and...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent Health (Providence, RI)
- …on-going training per inter-rater reliability process. + May assist the Senior Medical Director in research activities/questions related to the Utilization ... expert. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls)...support. + On a requested basis, may function as Medical Director for selecting health plans or… more
- Prime Therapeutics (Providence, RI)
- …of utilization management decisions. + On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability ... member of the utilization management team, and provides timely medical review of service requests that do not initially...fax. + Provides clinical rationale for standard and expedited appeals . + Provides assistance and act as a resource… more