- Elevance Health (Topeka, KS)
- ** Provider Grievance and Appeals - Business Change Advisor** **Location: Topeka KS, or Olathe, KS** This position will work a hybrid model (remote and ... of one of our Kansas Elevance Health PulsePoint locations. The ** Provider Grievance and Appeals - Business Change Advisor** is responsible for… more
- Elevance Health (Los Angeles, CA)
- **Title: Grievance / Appeals Analyst I** **Location:** This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of ... one of our PulsePoint locations. The ** Grievance / Appeals Analyst I** is an entry level position in the Enterprise Grievance & Appeals Department that… more
- Elevance Health (Indianapolis, IN)
- Job Description **Title: Grievance / Appeals Analyst I** **Location:** This position will work a hybrid model (remote and office). Ideal candidates will live ... within 50 miles of one of our PulsePoint locations. The ** Grievance / Appeals Analyst I** is an entry level position in the Enterprise Grievance & Appeals … more
- Elevance Health (Mason, OH)
- …and plan risk, ensures quality, and regulatory compliance.** PRIMARY DUTIES: + Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings. + ... Leads grievance and appeals in regulated audits. +...a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical… more
- Baylor Scott & White Health (Temple, TX)
- … Grievance Specialist performs reviews, within operational aspects, of the member and provider complaints, appeals and grievance cases for products for ... of cases; review, research and coordination of complaints, grievances, appeals and reconsiderations consistent with statutory and federal regulatory guidelines.… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, September 9, 2024 Centers Plan for Healthy Living's goal ... the guidance and plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial… more
- Henry Ford Health System (Troy, MI)
- …prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare ... Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business . Analyst must identify trending issues on an ongoing basis and provide root/cause… more
- Elevance Health (Costa Mesa, CA)
- **Manager I - Grievances & Appeals - Provider Disputes** **Location** : This position will work a hybrid model (in office 1-2 days per week). The ideal candidate ... for the management oversight of receipt, investigation and processing associated with member/ provider grievances and appeals . **How you will make an impact:**… more
- Commonwealth Care Alliance (Boston, MA)
- …oversight, and compliance. + Develop and execute on strategic opportunities to improve appeals & grievance process to support a best-in-class A&G operation that ... to Us:** **Position Summary:** Reporting to the Director of Appeals & Grievances, the Manager, Appeals &...and resolved using regulatory guidance across all lines of business . This role provides direct supervision to staff to… more
- Elevance Health (Rancho Cordova, CA)
- …will make an impact:** + Conducts investigations and reviews of member and provider medical necessity appeals . + Reviews prospective, inpatient, or retrospective ... **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
- Humana (Tallahassee, FL)
- …Degree + Previous inbound call center or related customer service experience + Grievance and appeals experience + Bilingual (English and Spanish); with the ... and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by...review of clinical documentation to determine if an a grievance , appeal or further request is warranted and then… more
- Humana (Columbus, OH)
- …+ Previous inbound call center or related customer service experience + Previous grievance and appeals experience + Medical terminology experience + Bilingual ... and help us put health first** The Grievances & Appeals Representative 2 manages client denials and concerns by...review of clinical documentation to determine if an a grievance , appeal or further request is warranted and then… 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 ... not limited to:** + Conducts investigations and reviews of member and provider quality concerns. + Reviews prospective, inpatient, or retrospective medical records.… more
- 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** 40 ... Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director reviews cases of diverse scope and complexity… more
- CareFirst (Baltimore, MD)
- …management decisions themselves and the consequences of those decisions by way of appeals , for all lines of business that result in demonstrable impacts ... of their week at a CareFirst location based on business needs and work activities/deliverables that week. **PURPOSE:** Under...Appeals , Grievances & Clinical Medical Review: Oversees the Appeals and Grievance function as well as… more
- CareOregon (Portland, OR)
- …process to members, providers and CareOregon staff. + Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare ... appeals and notify members and providers of outcome. + Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement… 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...the available information and as well as research and provide a written detailed clinical summary for the Plan… more
- CVS Health (Trenton, NJ)
- …information from Providers, such as HEDIS, Credentialing, Grievance and Appeals , SIU, etc. Coordinates provider status information with member services ... Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards +… 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 ... desirable) AND A bachelor's degree in public or business administration, human resources management, organizational development, or industrial psychology from an… more
- Highmark Health (Dover, DE)
- …This position is also responsible for assisting members in navigating the grievance and appeals process and representing member interests internally and ... serving as a liaison between the member, the Health Plan, and the provider for the Highmark Delaware Medicaid product. The position conducts telephonic support to… more