- Maximus (New York, NY)
- …responsible for medical reviews and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals , following project guidelines. Essential Duties and ... for reviewing documentation and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals , following project guidance - Review, organize… more
- VNS Health (Manhattan, NY)
- …(LCSW) in New York State or other independent licensure (LMHC, LMFT, clinical psychologist, or psychiatric Nurse Practitioner). requiredLicensure in other states ... VNS Health is seeking a Social Work Licensed Clinical Social Worker for a job in Manhattan,...BH QM/UM and performance improvement activities, encompassing grievances and appeals , and contributes to various other subcommittees such as… more
- CareFirst BlueCross BlueShield (Baltimore, MD)
- …for authorization of services and approved claims. Oversees retrospective reviews, case appeals , billing coordination, and clinical support. Ensure that staff is ... Resp & Qualifications PURPOSE: We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a… more
- CareFirst (Baltimore, MD)
- …for authorization of services and approved claims.Oversees retrospective reviews, case appeals , billing coordination, and clinical support.Ensure that staff is ... We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be… more
- R1 RCM (Salt Lake City, UT)
- …platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals Nurse ** , you will help our ... remote, production-driven position. **Here's what you will experience working as a Clinical Appeals Nurse :** + Conduct a detailed review of patient medical… more
- Molina Healthcare (Georgetown, KY)
- …for appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions… more
- R1 RCM (Chicago, IL)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse ** , you will help ... remote production-drive position. **Here's what you will experience working as a Clinical Coding Appeals Nurse :** + Review and interpret medical records to… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, ... safety net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II… more
- Elevance Health (Rancho Cordova, CA)
- ** Nurse Appeals - Licensed RN Nurse.../grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting ... locations. **Shift:** Monday to Friday from 8:00-5:00 pm PT The ** Nurse Appeals ** is responsible for investigating and processing medical necessity appeals… more
- CareFirst (Baltimore, MD)
- …programs/plans (all benefits/incentives are subject to eligibility requirements). **Department** Clinical Appeals and Analysis **Equal Employment Opportunity** ... all lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State...goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance… more
- Centene Corporation (Austin, TX)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... a candidate who resides in Texas. **Position Purpose:** Performs clinical reviews needed to resolve and process appeals...processes is preferred. **License/Certification:** + LPN - Licensed Practical Nurse - State Licensure required or + LVN -… more
- Elevance Health (Los Angeles, CA)
- ** Nurse Appeals (Quality) - California candidates.../grievances/quality of care issues and is a resource for clinical and non clinical team members in ... **Preferred Capabilities, Skills and Experiences:** + ER experience preferred. + Appeals /Quality of care experience preferred. + Managed Care experience preferred. +… more
- HCA Healthcare (Nashville, TN)
- …our HCA Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Clinical Appeals Team Lead with Parallon you can be a part of an ... in our organization. We are looking for an enthusiastic Clinical Appeals Team Lead to help us...Unlock your potential! **Job Summary and Qualifications** The Compliance Nurse Team Lead is responsible for providing clinical… more
- CVS Health (Hartford, CT)
- …zone of residence. **Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and interprets data obtained from ... active and unrestricted RN licensure in state of residence + 3+ years clinical experience **Preferred Qualifications** + Appeals Experience + Managed Care… 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 ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- Genesis Healthcare (Philadelphia, PA)
- …to be paid. RESPONSIBILITIES/ACCOUNTABILITIES: Reviews patient medical records; utilize clinical , regulatory knowledge and skills to provide convincing appeal ... be in breach of published regulations or payer policy guidelines.Uses clinical evidence and/or regulatory arguments to prove appeal reasoning.Participates in… more
- St. Mary's Healthcare (Amsterdam, NY)
- …based on experience and other factors permitted by law. Responsibilities: * Uses clinical and coding knowledge to ensure accurate and compliant charge items and to ... and audit requests and coordinates attempts to overturn denials by drafting appeals , negotiating with payers, or following up with payer utilization review… more
- VNS Health (Manhattan, NY)
- …Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + ... to day activities for staff handling of grievances and appeals for one of the following VNS Health Plans...quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or… more
- Carle (Urbana, IL)
- …resource in outpatient clinical documentation review to establish and manage clinical and prior authorization denial appeals for the Carle enterprise. ... Represents Carle in clinical meetings and writing appeals on outpatient accounts where medical necessity, level of care or prior authorization is questioned.… more
- Baylor Scott & White Health (Temple, TX)
- …expedited and external case reviews, and prepares final case submissions. + Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for ... **JOB SUMMARY** The Appeals and Grievance Specialist performs reviews, within operational...within operational aspects, of the member and provider complaints, appeals and grievance cases for products for all lines… more
