- HCA Healthcare (Nashville, TN)
- …patients with purpose and integrity. We care like family! Jump-start your career as a Clinical Appeals Team Lead Nurse today with Parallon. **Benefits** ... for benefits may vary by location._** Come join our team as a Clinical Appeals Team Lead Nurse. We care for our community! Just last year, HCA… 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
- Elevance Health (Richmond, VA)
- **Title: Grievance/ Appeals Analyst Lead ** **Location:** This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of ... a California PulsePoint location. The **Grievance/ Appeals Analyst Lead ** will be responsible for...** will be responsible for leading and coaching a team of Grievance & Appeals Analysts in… more
- Elevance Health (Norfolk, VA)
- …**Grievance/ Appeals Analyst Lead ** is responsible for leading and coaching a team of Grievance & Appeals Analysts in the Enterprise Grievance & ... **Grievance/ Appeals Analyst Lead ** **Candidates must be...and process pre service and post service grievances and appeals requests related to clinical and non… more
- Commonwealth Care Alliance (Boston, MA)
- …This Role is Important to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances, the Manager, Appeals & Grievances (A&G) Audit and ... Oversight is responsible for the oversight of Plan level appeals and grievances within the Appeals &...Doing:** **Essential Duties & Responsibilities:** + Effectively manage a team to ensure a positive team environment,… more
- Trinity Health (Springfield, MA)
- …Shift **Description:** Requires BSN At **Mercy Medical Center** the **Utilization Review/ Appeals & Denials** **RN** performs utilization review with payers, assists ... Nurse, ICC and Social Worker with utilization management and clinical coordination of the patient's hospital stay. Comply with...Educate patient, families and other members of the care team about the financial out of pocket expense or… more
- Glens Falls Hospital (Glens Falls, NY)
- …MCC's and CC's for reimbursement. In collaboration with Hospital External Review Team (HERT) members, coordinates reviews and responds to internal and external ... but with emphasis on Inpatient Coding. Collaborates with Professional Coders, Clinical Document Improvement Specialists, "Scrubber" Edit Specialists and Providers to… more
- Independent Health (Buffalo, NY)
- …and appeals , document research of initial coverage determinations, and lead coordination of clinical review with appropriate internal stakeholders and ... experience with managed care benefit plans. + Ability to research and assist clinical team in rendering coverage determinations in accordance with established … more
- CareFirst (Baltimore, MD)
- … clinical and diagnostic clinical operations strategy. The Vice President will lead and build a team of clinical operations professionals who oversee ... Case Management, Utilization Management including prior authorization, and post service clinical medical review and Appeals & Grievances operational functions… more
- LifePoint Health (Brentwood, TN)
- …hospital leadership. This position also provides oversight to the DRG Downgrade Appeals Specialist team . *Responsibilities:* . Oversee the operations and human ... to maintain and improve KPIs. . Develop and execute appeals management strategies for the DRG downgrade team...within the medical record and evidence-based literature. . Ensure appeals follow current industry clinical guidelines, evidence… more
- CVS Health (Phoenix, AZ)
- …executing and maintaining PA Administration (PA Admin) requirement tools and lead /facilitate improvements for the PA& Appeals Client Support organization. ... and direction to the prior authorization operations management teams within the Clinical Services PA Administration department. This leader will be responsible for… more
- Medical Mutual of Ohio (OH)
- …complex outpatient, inpatient and professional claim irregularities, overpayments and provider appeals from a clinical coding perspective, applying coding ... abnormalities, questionable billing practices and proper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …encompasses a member and provider call center, provider correspondence and appeals , clinical review, member correspondence and reconsiderations, enrollment, ... environment. This manager also has direct oversight to a team of clinical (RN) reviewers and offers...the Associate Director of FEP Operations. Key Accountabilities: + Lead and motivate a team by creating… more
- State of Colorado (Arapahoe County, CO)
- CORRECTIONAL, YOUTH, OR CLINICAL SECURITY SUPERVISOR III - Marvin W. Foote YSC in Englewood, CO Print ... (https://www.governmentjobs.com/careers/colorado/jobs/newprint/4691496) Apply CORRECTIONAL, YOUTH, OR CLINICAL SECURITY SUPERVISOR III - Marvin W. Foote YSC in… more
- CareOregon (Portland, OR)
- …collaboration in a CCO environment This position may be assigned to lead medical management, clinical informatics, behavioral health, and/or population health ... This position is responsible for leading a multidisciplinary, matrixed team in supporting both internal staff, as well as...clinical systems. + May plan, participate in, or lead CCO Clinical Advisory Panel (CAP), depending… more
- Elevance Health (Cerritos, CA)
- …consistent with applicable clinical criteria. + Provide education regarding applicable clinical criteria. + Perform first level provider appeals of coverage ... procedures. Medical Directors determine the medical necessity of requests using clinical appropriateness guidelines. The **Associate Medical Director, Clinical … more
- Elevance Health (Colorado Springs, CO)
- …of a Client Services Team (CST), including Account Executive, Account Services Lead , Medical Directors, Clinical Lead , and Provider Relations Lead ... Leadership, health plan clientele, Performance Measurement Improvement/Quality Analytics, Accreditation, Clinical , Medical, and Provider Relations team members.… more
- Nuvance Health (Danbury, CT)
- …optimize patient outcomes. 3. Denials Management & Appeals : Root Cause Analysis: Lead a specialized team to thoroughly investigate claims denied for medical ... of case managers, utilization review staff, denials and appeals specialists, and non- clinical support staff. This...UR committee meetings. 2. Utilization Review (UR): Proactive UR: Lead a team of UR nurses to… more
- Kepro (Graham, NC)
- …a vital partner for health solutions in the public sector. Acentra Health seeks a Clinical Assessor to join our growing team . Job Summary: Acentra Health is ... to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions...innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra… more
- Elevance Health (Grand Prairie, TX)
- …development of new clinical products. + Oversees the Front End operations team in mail order pharmacy. + Responsible for oversight of Pharmacists and technicians ... **Manager Pharmacy Clinical Operations (Mgr Pharmacy Clinical Ops)-...the United States when conducting utilization review or an appeals consideration and cannot be located on a US… more