- Centene Corporation (Jefferson City, MO)
- …plan leaders and cross functional stakeholders across the enterprise. + Provide medical leadership for all utilization management ( appeals ), pharmacy, case ... and pharmacy consultants for reviewing complex cases and medical necessity appeals . + Participate in provider...would improve utilization and health care quality. + Review claims involving complex, controversial, or unusual or new services… more
- Covenant Health Inc. (Knoxville, TN)
- Overview Insurance Appeals Senior , Revenue Integrity and Utilization Full Time, 80 Hours Per Pay Period, Day Shift Covenant Health Overview: Covenant Health is ... integrity auditor to take appropriate action. Prepares necessary documentation for insurance appeals process, ensuring timely follow through. Processes claim… more
- Mount Sinai Health System (New York, NY)
- …(Industry-Specific)** : + Healthcare: Experience with utilization management for medical services, procedures, or medications + Insurance : Understanding ... **Job Description** **Director Pre Appeals Management-HSO Appeals Management -Corporate 42nd...management program. This role ensures the appropriate use of medical resources, compliance with regulatory standards, and coordination of… more
- Point32Health (FL)
- …and Federal regulatory requirements + Manage the collection of documents and records ( medical , claims , administrative) needed to fully research the appeal or ... service or member services representative in health care or insurance + Preferred: 2 years' Appeals and...and comprehensive total rewards package which currently includes: + Medical , dental and vision coverage + Retirement plans +… more
- Elevance Health (Indianapolis, IN)
- …to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to ... analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or...Minimum of 3 years experience working in grievances and appeals , claims , or customer service; or any… more
- Point32Health (MA)
- …and Federal regulatory requirements + Manage the collection of documents and records ( medical , claims , administrative) needed to fully research the appeal or ... Summary** SUMMARY Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals ...and comprehensive total rewards package which currently includes: + Medical , dental and vision coverage + Retirement plans +… more
- Corewell Health (Grand Rapids, MI)
- … medical records, internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical , pharmacy ... and behavioral health authorizations, customer service interactions, prescription claims , medical policies, and plan documents).Evaluate information gathered to… more
- MTA (Brooklyn, NY)
- Assistant General Counsel III - Appeals , Torts Job ID: 12066 Business Unit: New York City Transit Location: Brooklyn, NY, United States Regular/Temporary: Regular ... Posted: Jul 10, 2025 Description Job Information Assistant General Counsel III - Appeals , Torts First Date of Posting: 7/10/2025 Last Date of Filing: Until Filled… more
- CareFirst (Baltimore, MD)
- …with the overall Corporate Strategic Plan through direction and oversight of the Clinical Medical Claims Reviews, Clinical Appeals and Analysis programs and ... & Qualifications** **PURPOSE:** We are looking for a Director, Medical Review & Appeals for our Government... insurance environment with a focus on Clinical Medical Review and Appeals and Grievances. **Preferred… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Job Summary** As the Supervisor, Appeals and Grievances you will oversee daily operations, staffing, and performance for a remote team of 15 Appeals & ... supporting our Pennsylvania Medicaid business. This role ensures that all provider appeals and grievance cases are processed accurately, timely, and in full… more
- Elevance Health (Indianapolis, IN)
- …law. The **Nurse Appeals ** is responsible for investigating and processing and medical necessity appeals requests from members and providers. **How you will ... make an impact:** + Conducts investigations and reviews of member and provider medical necessity appeals . + Reviews prospective, inpatient, or retrospective … more
- CareFirst (Baltimore, MD)
- …and responds to internal and external stakeholders, without breaching confidentiality of medical information. + Assists Supervisor and Appeals Specialist II and ... **Resp & Qualifications** **PURPOSE:** The Appeals Specialist I is responsible for the initial...in settings such as managed care, health care or insurance payor environment. **Preferred Qualifications:** + College Degree; previous… more
- AmeriHealth Caritas (Philadelphia, PA)
- …letters. **_Investigation and Resolution_** + Collaborate with internal departments such as Claims , Medical Management, Legal, and Compliance to obtain necessary ... . **This position is hybrid in Philadelphia, PA** **Job Summary** The Appeals & Grievance Case Resolution Specialist is responsible for the full life… more
- Elevance Health (Manchester, NH)
- **Title: Grievance/ Appeals Representative I** **Locations:** **Woburn, MA** **and** **Manchester, NH** This role requires associates to be in-office 1 - 2 days per ... unless an accommodation is granted as required by law._ The **Grievance/ Appeals Representative I** is responsible for reviewing, analyzing and processing member… more
- Centene Corporation (Austin, TX)
- …to optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex ... cases and medical necessity appeals . + Participates in provider...would improve utilization and health care quality. + Reviews claims involving complex, controversial, or unusual or new services… more
- Elevance Health (Plano, TX)
- **Referral Specialist I/Patient Access (Pre & Prior Authorizations, Appeals , Insurance ) - Paragon Infusion** **Location:** 3033 W President George Bush HWY., STE ... Medicare Local Coverage Determination is strongly preferred. + Knowledge of insurance verification, pre-authorization, and claims submission process is strongly… more
- CenterWell (Denver, CO)
- …Microsoft Access or experience with SQL Server databases + Previous experience processing medical claims + Bilingual (English and Spanish); with the ability to ... and appeal process. The Director, Home Health Grievances & Appeals assists members, via phone or face to face,...extends outside of work. Among our benefits, Humana provides medical , dental and vision benefits, 401(k) retirement savings plan,… more
- St. Luke's University Health Network (Allentown, PA)
- …health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all diagnosis and procedure ... APR-DRG for the purpose of appealing proposed DRG and coding changes by insurance providers or their respective auditors JOB DUTIES AND RESPONSIBILITIES: + Conduct… more
- Ochsner Health (New Orleans, LA)
- …The Appeals Specialist is responsible for managing and resolving insurance claim denials and underpayments to ensure accurate reimbursement. This role involves ... reviewing medical documentation, interpreting payer policies, and preparing detailed appeal...+ Experience in healthcare or revenue cycle - specifically insurance claim denials. + Strong analytical and organizational skills.… more
- St. Luke's University Health Network (Allentown, PA)
- …ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes ... MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors. Assures that the most accurate and descriptive… more
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