- CenterWell (Denver, CO)
- …compliance. Manages the Denials Management data analytics, denial and appeal process. The Director , Home Health Grievances & Appeals assists members, via phone ... a part of our caring community and help us put health first** The Director Denials Management provides leadership for the audit, appeal and review process to… more
- Humana (Frankfort, KY)
- …part of our caring community and help us put health first** The Corporate Medical Director provides medical interpretation and decisions about the ... and determining the best course of action. The Corporate Medical Director provides medical interpretation...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Possess analysis… more
- Molina Healthcare (Augusta, GA)
- …corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** We are looking for a Director , Medical Review & Appeals for our Government Programs lines of business. The incumbent will ... a managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances . **Preferred Qualifications:** + Significant… more
- UCLA Health (Los Angeles, CA)
- …Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Medical Director , Clinical Operations to help shape the future of our plan. ... In this key leadership role, you'll work closely with the Medical Director , Department of Health Services and play a vital part in scaling Health Services… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… more
- Trinity Health (West Springfield, MA)
- …The Director , Quality Improvement and Compliance, in collaboration with the Medical Director , is responsible for developing and implementing the annual QI ... implement the annual Quality Improvement (QI) Plan with the Medical Director + In conjunction with ...compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program.… more
- University of Washington (Seattle, WA)
- … Director , Clinical Risk Management, for UWMC, and to the Associate Director , Clinical Risk Manager for Harborview Medical Center for entity-specific ... Senior Clinical Risk Manager works in close collaboration with UW Medical Directors, Chief Nursing Officers, individual health professionals, directors, and managers… more
- State of Colorado (Brighton, CO)
- …This position ensures compliance with nondiscrimination policies and manages grievances related to discrimination. This position manages complaints, develops ... + Review of videos involving physical response, abuse allegations, and youth grievances (if applicable). Additional reviews as required by the Youth Center… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… more
- State of Colorado (Pueblo, CO)
- …for 10 staff members, including direct supervision of 3 individual units: Medicare /Other Insurance, Medicaid/Self- pay, and Audit, including 3 professional staff, 6 ... disciplinary actions; approves leaves; assigns work schedules; resolves informal grievances ; establishes acceptable work standards; sets priorities; initiates hiring… more
- Elevance Health (Indianapolis, IN)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision....final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. +… more
- State of Colorado (Denver, CO)
- …security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- State of Colorado (Denver, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- State of Colorado (Centennial, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- Molina Healthcare (MA)
- …between Molina Healthcare and contracted provider network. In partnership with Director , manages and coordinates the Provider Services activities for the state ... outreach and resolving provider inquiries. * In conjunction with the Director , Provider Network Management & Operations, develops health plan-specific provider… more
- State of Colorado (Pueblo, CO)
- …safe, secure, and therapeutic setting for patients with both psychiatric and medical issues. The services provided include evaluation and treatment for patients who ... position is responsible for monitoring the nursing care (both psychiatric and medical ) provided to all patients. This position advocates for patients. This position… more
- WMCHealth (Margaretville, NY)
- …+ Keep abreast of economic conditions/situations and recommend to the Activity Director adjustments in activity programs that assure the continued ability to provide ... forms, reports, etc., and submitting such to the Activity Director as required. + Committee Functions + Serve on,...before entering a resident's room. + Review complaints and grievances made by the resident and make a written/oral… more
- STG International (Milledgeville, GA)
- …interviewing, screening and onboarding new staff in key positions. Assist the Director of Human Resources and department directors to develop written job ... properly identified and recorded. Coordinate with the Administrator and the Director of Human Resources regarding issues involving labor laws, progressive discipline… more
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