- CVS Health (Columbus, OH)
- …interventions. * Work with medical director teams focusing on inpatient care management , clinical coverage review, member appeals clinical review, ... and other complex health populations to optimize risk adjustment, clinical quality, and care management ....medical claim review, and provider appeals clinical review. * Actively participate in scheduled team meetings… more
- 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
- 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
- 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… 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 ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making...degree in Nursing preferred. **Required Experience** + 3-5 years clinical nursing experience, with 1-3 years Managed Care… 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
- 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
- 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
- Healthfirst (NY)
- …as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and Hyland. + Demonstrated ... Specialist to independently: + Research issues + Quality of Care Experience + Reference and understand HFs internal health...Hygienist Preferred Qualifications: + Bachelors degree + Experience in clinical practice with experience in appeals &… more
- Healthfirst (NY)
- …service, home health, hospital or doctors office preferred + Experience working in care management systems, such as CCMS, TruCare or Hyland + Demonstrated ... Duties and Responsibilities + Responsible for case development and resolution of non- clinical cases, such as: certain types of claim denials, member complaints, and… more
- Elevance Health (Richmond, VA)
- … and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. **How you will make an impact:** ... management review activities which require the interpretation of clinical information. + The analyst may serve as a...analyst may serve as a liaison between grievances & appeals and /or medical management , legal, and/or… 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 (Salem, OR)
- … 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
- Corewell Health (Grand Rapids, MI)
- …from enterprise-wide systems including: claims payments, billing and enrollment, care management , medical, pharmacy and behavioral health authorizations, ... + Working knowledge of Priority Health systems for claims payment, care management , authorizations, customer service interactions, pharmacy, Rx profiles,… more
- Centene Corporation (Harrisburg, PA)
- …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, ... Purpose:** Analyze and resolve verbal and written claims and authorization grievance/ appeals from providers and members. Resolve all State inquires related to… more
- CVS Health (Columbus, OH)
- …Health Care Delivery System eg, Clinical Practice and Health Care Industry. *Prior UM (Utilization Management ) experience *Active and current state ... 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… more
- UCLA Health (Los Angeles, CA)
- … or Medicare Advantage setting is highly desired * Experience in handling appeals , grievances, utilization management , or potential quality issues * Knowledge of ... Description As the Appeals & Grievances Nurse, you will play a...review of member and provider complaints, working closely with clinical and administrative teams. + Assessing cases to determine… more
- University of Michigan (Ann Arbor, MI)
- Revenue Cycle Coding Supervisor - Appeals & Denials Apply Now **Job Summary** The Denial Coding Supervisor provides subject matter expertise in physician medical ... activities. This position oversees the Physician Billing (PB) Denial Coders and Appeals and Denial Coordinators, ensuring the accuracy and efficiency of denial … more