- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals / Care /Case/Utilization Management /Quality. Strong verbal and written ... in Nursing Experience Required: Minimum of 8 years of acute/ clinical care experience. Minimum of 2 years...in a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... Directs the activities and serves as a resource for associates within the Clinical Appeals and Analysis unit. **ESSENTIAL FUNCTIONS:** + Provides direct… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …This position is eligible for the eWorker persona.The TeamAs an integral part of the Clinical Appeals team, the Appeals Nurse Reviewer will serve as a ... Medical and Payment Policy teams. Key Responsibilities: + Review provider claim appeals utilizing sound clinical judgement, medical policy, payment policy… more
- VNS Health (Manhattan, NY)
- …state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care ... OverviewResolves grievances, appeals and external reviews for one of the...VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Ensures… more
- Molina Healthcare (Columbus, OH)
- …be required. + Serves as a clinical resource for Utilization Management , Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides ... every 4 weeks Monday-Thursday and Wed - Saturday._** **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct … more
- 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...and DRG principles required. + Experience in a health care setting preferred. + Experience in appeals … more
- St. Luke's Health System (Twin Falls, ID)
- …a great place to work. **What You Can Expect:** Under limited supervision, the Clinical Appeals Specialist 2, is responsible for managing client medical denials ... sources to provide and maintain a single reporting location that reflects clinical denials and appeals activity. + Recommends improvements and modifications… more
- VNS Health (Manhattan, NY)
- …opportunities What You Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & ... Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care ...and Medicaid appeal and grievance processes, incidents, quality of care concerns and any other inquires requiring clinical… more
- LA Care Health Plan (Los Angeles, CA)
- …Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the… more
- Catholic Health Services (Melville, NY)
- …timely follow through. | Reviews providers' requests for services and coordinates utilization/ appeals management review. | Assist Utilization and Appeals ... | Keeps abreast of current changes affecting Utilization and Appeals Management as applicable. | Manages/follow-up on...current with industry standards and business objectives related to Care Management as appropriate. | Sound knowledge… more
- Healthfirst (AL)
- …Preferred Qualifications: + Bachelors degree + Case management / care management -QOC experience preferred + Experience in clinical practice with ... as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and Hyland. + Demonstrated… more
- Catholic Health Services (Melville, NY)
- …from the Managed Care Department and applies to UM and appeals management processes. Works collaboratively with physicians, physician office staff and ... medical-surgical or specialty experience required as applicable to position needs. Experienced appeals writer and Care Management experience required in an… more
- Catholic Health Services (Melville, NY)
- …from the Managed Care Department and applies to UM and appeals management processes. |Works collaboratively with physicians, physician office staff and ... medical-surgical or specialty experience required as applicable to position needs. |Experienced appeals writer and Care Management experience required in an… more
- ManpowerGroup (Columbia, SC)
- …industry, is seeking an Analyst, Appeals to join their team. As an Analyst, Appeals , you will be part of the clinical review department supporting the ... with applicable regulations or standards. + Perform thorough research of service appeals based on clinical documentation, contractual requirements, and policies.… more
- CVS Health (Providence, RI)
- … system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. **This is a ... appeals to the appeal nurses and territory Utilization Management staff. * Participate in ongoing initiatives to improve...(2) or more years of experience in a Health Care Delivery System eg, Clinical Practice or… more
- CVS Health (Hartford, CT)
- … system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. **This is a ... ongoing education/ subject matter expertise regarding Medicare policy and appeals to the territory Utilization Management staff...(2) or more years of experience in a Health Care Delivery System eg, Clinical Practice or… more
- HCA Healthcare (Nashville, TN)
- …meaningful as we do. We want you to apply! **Job Summary and Qualifications** The Clinical Appeals Analyst is responsible to support the Attorney serving in the ... team. Grow your career with an organization committed to delivering respectful, compassionate care , and where the unique and intrinsic worth of each individual is… more
- Community Health Systems (Fort Smith, AR)
- …+ Assists case workers with pre-certification and authorization issues related to appeals , providing necessary data for resolving inpatient/ clinical denials. + ... and resolution strategies. + Works closely with the Managed Care Department to address ongoing issues with contracted insurance...management skills to manage a high volume of appeals . + Proficiency in using healthcare billing software and… more
- Centene Corporation (Phoenix, AZ)
- …be the one who changes everything for our 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, ... or equivalent. Associate's degree preferred. 2+ years grievance or appeals , claims or related managed care experience....grievance or appeals , claims or related managed care experience. Strong oral, written, and problem solving skills.… more
- Centene Corporation (Tallahassee, FL)
- …be the one who changes everything for our 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, ... **Two (2) years of leadership, hospital claims, and provider post service appeals experience strongly preferred.** **Position Purpose:** Supervise the day to day… more