- Humana (Columbus, OH)
- …to protect member PHI / HIPAA information This is a remote position reporting to Grievance and Appeals Director or MD Team Lead **Scheduled Weekly Hours** ... on medical background and reviews health claims and preservice appeals . The Corporate Medical Director reviews cases of diverse scope and complexity ranging from… more
- VNS Health (Manhattan, NY)
- …requirements. Also monitors and audits subcontractors who have delegated responsibility for managing grievance and appeals on behalf of the plan to ensure ... case file and data collection systems and prepares data reports and analysis of grievance and appeals for program management and committees, as needed. Works… more
- CVS Health (St. Paul, MN)
- …remote based (work at home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Medicare Appeals . * Direct daily work on ... Recognized Specialty **Preferred Qualifications** * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances, the Manager, Appeals & Grievances (A&G) Audit ... to the policies and procedures as assigned by the Director . Partner with A&G Operations Manager and the A&G...+ Develop and execute on strategic opportunities to improve appeals & grievance process to support a… more
- Elevance Health (Rancho Cordova, CA)
- …+ Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved ... **Nurse Appeals - Licensed RN Nurse** **Location:** This position...timely to meet regulatory timeframes. + Documents and logs appeal/ grievance information on relevant tracking systems and mainframe systems.… 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, CA, US, ... net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct… more
- Elevance Health (Los Angeles, CA)
- **Nurse Appeals (Quality) - California candidates only** **Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health ... medical records. + Extrapolates and summarizes medical information for medical director , consultants and other external review. + Prepares recommendations to assign… more
- Humana (Columbus, OH)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Humana (Columbus, OH)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement...member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors… more
- CVS Health (Columbus, OH)
- …management, care management, claims adjudication, pharmacy utilization, quality improvement, grievance and appeals , policies and procedures, and responsible ... and policies. **Primary Job Duties & Responsibilities:** Behavioral Health Medical Director + Collaborates with health plan Sr Leadership to identify, develop,… more
- City of New York (New York, NY)
- …from the approximately 19,000 lane-miles of City streets. DSNY is seeking a Director of Labor relations to provide consistent contractual and legal interpretation of ... labor laws. Reporting directly to the Deputy Commissioner of Human Capital, the Director of Labor Relations will administer the Agency's labor relations program. The… more
- UPMC (Moosic, PA)
- We have an exciting opportunity for a full-time Senior Medical Director to join our leadership team with UPMC Community Care! As Senior Medical Director , you ... to learn more and apply today! The Senior Medical Director provides guidance for clinical operational aspects of the...and action at all stages of the complaint and grievance process. + Works with Provider Relations to enhance… more
- Humana (Columbus, OH)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors may join a centralized team ... of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations… more
- Humana (Columbus, OH)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations… more
- Fairfield University (Fairfield, CT)
- …to student appeals of accommodations in accordance with the University's grievance policies and procedures; 4) In partnership with the Assistant Vice President ... **Job Description:** **Position Title: Director - Office of Accessibility (OOA)** **Reports To**...(Division of Student Life) **Position Description and Summary** The Director will provide leadership and strategic oversight for the… more
- DOCTORS HEALTHCARE PLANS, INC. (Coral Gables, FL)
- …potential quality/compliance issues. + Voting member of the Quality Improvement Committee, Appeals and Grievance Committee, and Medical Management Committee. + ... team. + Responsible for managing the operations of the Quality of Care / Quality of Service Grievance Department. + Ensure systematic identification and follow-up of… more
- Elevance Health (Chicago, IL)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Sign-on Bonus:** $10,000 The **Clinical Operations Medical Director ** is responsible for supporting the medical management staff ensuring timely and consistent… more
- The Cigna Group (Bloomfield, CT)
- …with every other weekend (Tuesday ALT Day).** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part C + Ability to ... differentiate different types of requests Appeals , Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of… more
- Sacramento County (Sacramento, CA)
- …duties, including a minimum of one year experience in discipline, grievance investigation, arbitration, or labor negotiations (public sector experience is highly ... of the total possible score as determined by the Director . APPEAL PROCESS: Persons who believe their applications have...Street, Room 2640, Sacramento, CA 95814, telephone: ###. Such appeals must be filed within thirty (30) calendar days… more
- MTA (New York, NY)
- …and participate in monthly conferences with union representatives to discuss contract grievance and employee discipline appeals ; perform analytical review of ... : 551 DEPT/DIV : Labor Relations SUPERVISOR : Assistant Director , Labor Relations LOCATION : 420 Lexington Ave, 11th...sanctioned by the National Mediation Board for all contract grievance and employee discipline cases. + Provide leadership and… more