- Humana (Boston, MA)
- …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
- Highmark Health (Boston, MA)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… more
- CVS Health (Boston, MA)
- …care more personal, convenient and affordable. **Job Purpose and Summary:** The Dental Director - Medicare Appeals is an individual contributor who will assure ... Quality Management processes, including credentialing, site assessments, peer review, complaints, grievances and appeals (CGA) + Consults and lends expertise… more
- Beth Israel Lahey Health (Westwood, MA)
- …address information. Escalates calls to pharmacists for clinical inquiries and escalates grievances to supervisor. 7. Maintains new and existing patient profiles and ... Support health care providers with required prior authorization and required appeals . Manage all mail/delivery of Rx orders including addressing problems/issues with… more
- Point32Health (Canton, MA)
- …met + Track stakeholder feedback on product performance throughout the year, including Appeals & Grievances to help inform future benefit design guidance, ... are approved by senior leadership, the Senior Manager, in collaboration with the Director , is responsible for all necessary product filings with CMS and other… more