- 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
- Humana (Tallahassee, FL)
- …population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees. \#physiciancareers ... Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time… more
- Prime Therapeutics (Tallahassee, FL)
- …web-based application and spreadsheets. + Supports clinical services such as the appeals program. + Participates in meetings and consults with management on regular ... basis to discuss member interaction and program outcomes. + Maintains appropriate par levels of literature. + Familiarizes self with community resources available, benefit information or any other information that is valued with the program. + Maintains an… more
- Ralliant (Tallahassee, FL)
- …ROI. Create compelling product messaging that differentiates our products and appeals to target audiences. Translate product enhancements into effective messaging ... and programs. + **Fortive Business System:** Leverage the Fortive Business System tools to streamline and standardize best practices across Hengstler-Dynapar Sales. **Qualifications:** + Bachelor's degree in a technical or business field required; an MBA is a… more
- Lincoln Financial (Tallahassee, FL)
- …Works directly and independently with sales to address case issues and appeals , with little direction from underwriting management. * Negotiates more complex ... benefits & pricing on non-experienced rated & experienced rated cases with brokers & representatives. * Analyzes financial health, performance, operations, and personnel levels of customers to determine if additional safeguards or conditions should be included… more
- Growth Ortho (Tampa, FL)
- …compliance issues. Lead the resolution of payer disputes and oversee appeals or escalations as necessary. Cross-Functional Collaboration Work closely with the ... Revenue Cycle, Finance, Operations, and Clinical teams to ensure alignment on payer initiatives and revenue goals. Support the integration of newly acquired practices or ASCs into GO's payer strategy framework. Analytics & Performance Monitoring Develop and… more