- CareFirst (Baltimore, MD)
- …business needs and work activities/deliverables that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple ... managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances. **Preferred Qualifications:** + Applicants… more
- CVS Health (Hartford, CT)
- …based (work at home) based anywhere in the US.**Responsibilities of this Medical Director role are related to Medicare Appeals .* Direct daily work on part C ... encumbrances* Board Certified in ABMS Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience.*… 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 ... scope and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the… more
- Martin's Point Health Care (Portland, ME)
- …member and provider appeals for review by clinical team, including medical director . + Prepares and sends appeal case files for all appeal levels ... Place to Work" since 2015. Position Summary Job Description Position Summary: The Appeals Specialist (Medicare or US Family Health Plan) is responsible for ensuring… more
- LA Care Health Plan (Los Angeles, CA)
- …Works with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary ... and management of the A&G Nurse Specialist, RN and/or Medical Director . This position provides assistance to... and determination. Performs clinical review of medical records related to grievances and appeals .… 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 ... on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance with… more
- Centene Corporation (New York, NY)
- …guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review + Prepare case review ... the prescribed NCQA timeframes and appeals turnaround database + Assist the Medical Director with revising, updating and/or creating new policies to satisfy… more
- Trinity Health (Darby, PA)
- …Medicaid patient case reviews in accordance with state guidelines + Ensures timely review of appeals including case preparation with all relevant documentation, ... **Employment Type:** Full time **Shift:** Day Shift **Description:** The Appeals and Utilization Management Coordinator under direction and in...scheduling and processing the review to be conducted by the Physician Advisor to… more
- LA Care Health Plan (Los Angeles, CA)
- …Procedures, in a consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all line of business ... This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as...evaluation by the Management Team. Duties Focus on quality review of grievance and appeals cases for… more
- Elevance Health (Knoxville, TN)
- …+ Extrapolates and summarizes medical information for medical director , consultants and other external review . + Prepares recommendations to either ... uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.… more
- City of Detroit (Detroit, MI)
- …The Detroit City Council is seeking qualified applicants for the appointive position of Director of the Board of Zoning Appeals to serve as the administrative ... Dir Board of Zoning Appeals Print (https://www.governmentjobs.com/careers/detroit/jobs/newprint/4562523) Dir Board of Zoning...undertake the following tasks: + Plan, organize, assign, direct, review and coordinate the activities of the BZA staff… more
- Centene Corporation (IA)
- …letters are compliant with State and NCQA standards. + Maintain files and logs for all appeals + Coordinate with Medical Director (s) to clarify medical ... State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of… more
- University of Utah (Salt Lake City, UT)
- …**Requisition Number** PRN38907B **Job Title** Outpatient/Provider Coder Level 3 **Working Title** Medical Appeals Coding Specialist SR **Job Grade** E **FLSA ... of U Health - Academics **Department** 00209 - Univ Medical Billing - Oper **Location** Other **City** Other **Type...summarizing payer concerns and escalating for resolution. 5. Quality Review of team for appropriate coding and documentation (… more
- CVS Health (Springfield, IL)
- …individual client requested coverage determinations or appeals when appropriate.- Medical Directors will participate in inter-rater review activities and ... Fortune 6 company, has an outstanding opportunity for a Medical Director ( Medical Affairs).The ...requested coverage determinations or appeals when appropriate.- Medical Directors will participate in inter-rater review … more
- AmeriHealth Caritas (Orlando, FL)
- ** Medical Director , UM Review , Family Medicine** Location: Orlando, FL Primary Job Function: Medical Management ID**: 31409 **Job Brief** Must be able to ... practice in any state licensed in as a medical director . Additional state licensure required in...leadership in the operational areas of care management, utilization review , appeals , quality improvement and related policy… more
- City and County of San Francisco (San Francisco, CA)
- …health services, including psychiatric services. The Behavioral Health Services (BHS) Deputy Medical Director of Managed Care provides effective leadership and ... clinical responsibilities with the remaining 70-90% dedicated to Deputy Medical Director responsibilities, which include: + Supports...under Civil Service Rule 111A.35.1. The standard for the review of such appeals is 'abuse of… more
- Humana (Columbus, OH)
- …how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer based review of moderately complex to complex ... caring community and help us put health first** The Medical Director relies on medical ...group practice management. + Utilization management experience in a medical management review organization, such as Medicare… more
- Humana (Columbus, OH)
- …will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex ... caring community and help us put health first** The Medical Director relies on medical ...group practice management. + Utilization management experience in a medical management review organization, such as Medicare… more
- Highmark Health (Charleston, WV)
- …and providers across the network. + Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned. + ... outcomes. A key component of this role is to review denials of care based on medical ...There are a variety of external contacts that the Medical Director would be anticipated to regularly… more
- CVS Health (Springfield, IL)
- …and providers related to precertification, concurrent review , and appeal request. The Medical Director is a work-at-home position located anywhere in the US. ... reviews with peer to peer coverage of denials. * Appeals - The medical director ...Medicaid) Experience with managed care (Medicare and Medicaid) utilization review preferred MD or DO; Board certification in an… more