- CVS Health (Hartford, CT)
- …in the US.**Responsibilities of this Medical Director role are related to Medicare Appeals .* Direct daily work on part C appeals (both provider and ... policy for the enterprise* Provide ongoing education regarding Medicare policy and appeals to the appeal...Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience.* Health… more
- Humana (Columbus, OH)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- CVS Health (Hartford, CT)
- …Senior Manager of Learning and Development, you are a strategic partner for the Aetna Medicare CTM, Grievances & Appeals business. You are a people leader with ... Human Resources business unit and report to the Lead Director of Enterprise Training. A day in the life...positive, measurable performance results for the Aetna Grievances & Appeals business unit. You will thrive in a rapidly… more
- CareFirst (Baltimore, MD)
- …Strategic Plan through direction of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs ... needs and work activities/deliverables that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical… more
- Martin's Point Health Care (Portland, ME)
- …on clinical member and provider appeals for review by clinical team, including medical director . + Prepares and sends appeal case files for all appeal levels ... manner. The Specialist communicates and collaborates with Case Managers, Medical Directors and Compliance partners, as well as other...Health Plan benefits, particularly as it relates to Member Appeals + Cross-trains with Medicare Appeals… more
- Trinity Health (Darby, PA)
- **Employment Type:** Full time **Shift:** Day Shift **Description:** The Appeals and Utilization Management Coordinator under direction and in collaboration with the ... Manager, provides support to the utilization management, denials and appeals process for the THMA South hospitals. The ...are met + Collaborates with Physician Advisor to clarify medical necessity or clinical rationale + Assists in corresponding… more
- Fallon Health (Worcester, MA)
- **Overview** **The Member Appeals and Grievances Intake Administrator is working M - F 8 am to 5 pm in the office 5 days/week. We are looking for someone that is ... to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)-… more
- LA Care Health Plan (Los Angeles, CA)
- …the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director . This position provides assistance to members with health care ... authorization evaluation. Investigates Provider Disputes/PDR and prepares clinical summary for Medical Director determination. Work with the external providers… more
- LA Care Health Plan (Los Angeles, CA)
- …required by clinical staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in meeting regulatory timelines by ... Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive… more
- Humana (Columbus, OH)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of… more
- Elevance Health (Richmond, VA)
- …office locations Work schedule: Monday - Friday, standard business hours.** The Medical Director Clinical Programs is responsible for designing and implementing ... of Elevance Health's family of brands, offering Medicaid and Medicare plans in several states. We also provide administrative...clinical programs with specific medical condition focus for all lines of business enterprise… more
- CVS Health (Harrisburg, PA)
- …care more personal, convenient and affordable. Job Purpose and Summary: The Dental Director - Commercial and Medicare Advantage is an individual contributor who ... This role will be a key partner to the Medicare business segment. + The Dental Director ...including credentialing, site assessments, peer review, complaints, grievances and appeals (CGA) * Consults and lends expertise to other… more
- Avispa Technology (Los Angeles, CA)
- Financial Analyst - Medicare and Medi-Cal 2510506 (H) One of the most prestigious and well-known universities is seeking a Financial Analyst. The successful ... and statistical information required for completion of the annual Medicare and Medi-Cal cost report. The ideal candidate has...the office approx. 4 times/year) * W2 Employment, Group Medical , Dental, Vision, Life, Retirement Savings Program, PSL *… more
- CVS Health (Springfield, IL)
- …assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and… more
- Humana (Columbus, OH)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and … more
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... with the corporation maximize their effectiveness. + Grievances and Appeals - Assist in the evaluation and resolution of...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- CVS Health (Springfield, IL)
- …will perform concurrent and prior authorization reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals in ... services to its membership. Aetna is looking for a Medical Director to be part of a...Two (2) + years of experience in managed care ( Medicare and/or Medicaid) Experience with managed care ( Medicare… more
- Molina Healthcare (Bothell, WA)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Molina Healthcare (Bothell, WA)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Centers Plan for Healthy Living (Staten Island, NY)
- …and HHCAHPS sites to obtain quality data. + Oversight of Medicare Expedited appeals and conventional Medicare appeals process. Maintains records of all ... Director Quality Management/Compliance Officer 75 Vanderbilt Ave, Staten...appeals . Serves as the Agency's contact with the Medicare QIO. + Oversight of risk management, including documentation… more