- AdventHealth (Apopka, FL)
- …communicates effectively with patient and prescriber regarding prior authorizations, appeals , copayments and limited distribution drugs + Contacts prescribers' ... office regarding clarification on missing prescription information and/or prescription coverage details including prior authorization requirements, keeping the patient informed on any delays in processing time Qualifications **The expertise and experiences… more
- Elevance Health (Tampa, FL)
- …alternative surgical and non-surgical treatments. + Performs first level provider appeals of coverage decisions. + Provides support and education to internal ... clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management. + Participates in physician team meetings. + Participates in groups that develop, revise and enhance clinical… more
- Bristol Myers Squibb (Tampa, FL)
- …for escalation and resolution of Tier 2 queries, plan interpretation and appeals . + Responsible for ensuring internal processes are documented and updated versions ... are maintained. + Responsible for ensuring Knowledge Articles are updated and provide recommendations for content articles to resolve common questions. + Supports communicating change and develops and delivers ongoing learning/development of functional… more
- CVS Health (Tallahassee, FL)
- …written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals . - Ensures all compliance requirements are satisfied and all ... payments are made against company practices and procedures. - Identifies and reports possible claim overpayments, underpayments and any other irregularities. - Performs claim rework calculations. - Distributes work assignment daily to junior staff. - Trains… more
- CBRE (Jacksonville, FL)
- …financing, insurance replacement cost calculation, estate valuation, tax appeals , equitable distribution, corporate employee relocation, investment, or sale. ... + Maintain organizational reputation by conforming to the Uniform Standards of Professional Appraisal Practice (USPAP); keeping information confidential. + Update job knowledge by following current real estate values and property development potential,… more
- Evolent (Tallahassee, FL)
- …of best practices. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls) with requesting physicians ... or ordering providers, when available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s… more
- Highmark Health (Tallahassee, FL)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and ... concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
- Capgemini (Pensacola, FL)
- …software systems to create Prescription cases and determine coverage, determination and appeals process + Good written and verbal communication skills + The ability ... to display soft skills while moving the call forward + Meeting or exceeding government mandated timelines + Complying with turnaround time, productivity, and quality standards + Conveying resolution to beneficiary or provider via direct communication and… more
- City of Jacksonville (Jacksonville, FL)
- …Counsel (OGC) in cases, hearings and at various internal board hearings and appeals . + Attends meetings of the City Council, boards, agencies and OGC clients. ... + Assigns responsibility, takes corrective action, demonstrates leadership and evaluates, develops and motivates employees. + Performs other duties as assigned. Knowledge, Skills and Abilities + Knowledge of judicial procedures and rules of evidence, City… more
- HCA Healthcare (Orange Park, FL)
- …The Inpatient Coding Denials Specialist must ensure timely, accurate, and thorough appeals for all accounts assigned and apply critical thinking skills to ascertain ... root cause of denials. **What you will do in this role:** + Analyzes documentation to support codes/DRGs and abstracted data (eg, discharge disposition) for inpatient records for multiple facilities using ICD-10- CM and ICD-10-PCS to include: Principal… more