- UCLA Health (Los Angeles, CA)
- Description As the Appeals & Grievances Nurse , you will play a key role in managing and resolving New Century Health Plan member appeals and ... or Medicare Advantage setting is highly desired * Experience in handling appeals , grievances , utilization management, or potential quality issues * Knowledge… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Appeals and Grievances Clinical Operations RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... the safety net required to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing… more
- Molina Healthcare (Columbus, OH)
- …opportunities for improvement. **JOB QUALIFICATIONS** **Required Education** + Registered Nurse or equivalent combination of Licensed Vocational Nurse ... (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license. + OR Bachelor's or master's degree in Nursing, Gerontology, Public Health, Social Work, or related field. **Required Experience** + 5+ years of managed healthcare experience,… more
- Elevance Health (Walnut Creek, CA)
- ** Nurse Appeals - Licensed RN Nurse...forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet ... locations. **Shift:** Monday to Friday from 8:00am-5:00pm **PST** The ** Nurse Appeals ** is responsible for investigating and...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- VNS Health (Manhattan, NY)
- …opportunity to: * Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare ... high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. *...and current registration to practice as a registered professional nurse in New York State required Education: + Associate's… more
- CareFirst (Baltimore, MD)
- …This position will support the government programs line of business. 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 clinical skills and knowledge of all applicable State and… more
- TEKsystems (Rancho Cucamonga, CA)
- Grievance & Appeals Nurse (Hybrid - Rancho Cucamonga, CA) Pay: $31/hr Location: Hybrid - Rancho Cucamonga, CA 91730 Are you a dedicated Licensed Vocational ... to make an impact? We're hiring a Grievance & Appeals Nurse to ensure that healthcare cases...(CMS, DHCS, DMHC, NCQA). + Review and resolve medical grievances and coordinate care with providers. + Investigate quality-of-care… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances , appeals and external reviews for one of the following VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare ... each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with… more
- CareFirst (Baltimore, MD)
- …as needed. Reviews, researches problematic correspondence and works on special projects with Appeals Nurse or Management. + Interacts regularly with and responds ... are subject to eligibility requirements). **Department** MA and EGWP Appeals and Grievances **Equal Employment Opportunity** CareFirst BlueCross… more
- Baylor Scott & White Health (Temple, TX)
- …and resolution of cases; review, research and coordination of complaints, grievances , appeals and reconsiderations consistent with statutory and federal ... ROLE** + Maintains data entry requirements for all complaints, appeals and grievances . + Builds case files...case submissions. + Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for handling where required.… more
- Sacramento County (Sacramento, CA)
- Nurse Practitioner Print (https://www.governmentjobs.com/careers/sacramento/jobs/newprint/1780920) Apply Nurse Practitioner Salary $127,576.80 - $155,096.64 ... on: 9/27/2024, 10/25/2024, 11/22/2024, 12/27/2024, 1/31/2025, 2/28/2025, 3/28/2025, 4/25/2025 Nurse Practitioners provide a range of health care services involving… more
- State of Colorado (Canon City, CO)
- …reviews, and completing performance evaluations per CDOC regulations, and resolves complaints/ grievances at the informal level; + Ensures staff compliance with the ... daily monitoring, performance management (planning, reviewing and evaluating), resolving complaints/ grievances at the informal level, responsibility for scheduling and… more
- Centene Corporation (Olympia, WA)
- …expectations and lead clinical quality initiatives. Review clinical information for appeals to determine medical necessity of services, prepare reviews for cases, ... act as the liaison for appeals and fair hearings. + Develop and implement the...and resolve behavioral health quality of care complaints and grievances **Education/Experience:** Associate's degree in Nursing or other related… more
- Sharecare (Columbus, OH)
- …open enrollment / new hire plan selection, claims issues, ID card issues, grievances / appeals , utilization management (UM) status, including but not limited to ... payers or 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- HCA Healthcare (Rochester, NH)
- …At Frisbie Memorial Hospital, our nurses play a vital part. We know that every nurse 's path and purpose is unique. Do you want to create your own personal career ... payors, and hospital-negotiated contracts. Assists medical staff in responding to appeals . Provides requested information regarding patient care and services to… more
- State of Colorado (Colorado Springs, CO)
- …conflicts, investigates and problem solves internal and external complaints and grievances from staff, youth, family, and other customers. Scheduling of clinic ... Qualifications: Education/Licensure/Certification/Experience: Current, valid licensure as an Advanced Practice Nurse from the Colorado Board of Nursing; or current,… more
- Brighton Health Plan Solutions, LLC (Westbury, NY)
- …meets the standards for acceptable medical care. + Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively ... participates in the functioning of the plan's grievance and appeals processes. + Along with the nurse ...and appeals processes. + Along with the nurse supervisor and manager identify opportunities for improvement and… more
- Molina Healthcare (Columbus, OH)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Molina Healthcare (Columbus, OH)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… 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 + ... Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process + Educates and… more