• Director, Appeals & Grievances

    Molina Healthcare (St. Petersburg, FL)
    …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
    Molina Healthcare (07/20/25)
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  • Specialist, Appeals & Grievances

    Molina Healthcare (FL)
    …+ Responsible for the comprehensive research and resolution of the appeals , dispute, grievances , and/or complaints from Molina members, providers ... that internal and/or regulatory timelines are met. + Research claims appeals and grievances using support systems to determine appeal and grievance outcomes. +… more
    Molina Healthcare (06/26/25)
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  • Specialist, Appeals & Grievances

    Molina Healthcare (Orlando, FL)
    …to ensure that internal and/or regulatory timelines are met. + Research claims appeals and grievances using support systems to determine Provider No Surprises ... + Min. 2 years operational managed care experience (call center, appeals or claims environment). + Health claims processing background, including coordination… more
    Molina Healthcare (08/01/25)
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  • Director, Appeals & Grievances

    Molina Healthcare (Jacksonville, FL)
    …and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with the standards and requirements established by ... and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted… more
    Molina Healthcare (07/18/25)
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  • IRE Grievance & Appeals Mgr II

    Elevance Health (FL)
    …unless an accommodation is granted as required by law._ The **Manager II Grievance/ Appeals ** responsible for management oversight of grievances and appeals ... departmental units to investigate, resolve, and respond to grievances and appeals , manages inventory and production levels, and operational and plan risk,… more
    Elevance Health (07/15/25)
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  • Clinical Appeals Nurse (RN)

    Molina Healthcare (Tampa, FL)
    …and Marketplace request authorization. Strongly prefer candidates with a background in appeals and grievances . Excellent computer multi-tasking skills and good ... office with internet connectivity of high speed required **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for … more
    Molina Healthcare (08/02/25)
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  • Medicare Grievances and Appeals

    Humana (Tallahassee, FL)
    …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and… more
    Humana (06/18/25)
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  • Director, Operational Oversight (Medicare/Duals)…

    Molina Healthcare (Tampa, FL)
    …and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and quality functions. You ... 2. Workflow Integration - Embed CTM insights into downstream operations-Stars, appeals & grievances , enrollment, claims-so each team addresses systemic… more
    Molina Healthcare (07/13/25)
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  • Sr Specialist, Member Engagement (Remote)

    Molina Healthcare (Orlando, FL)
    …Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances , Member Problem Research and Resolution, and the ... advocate organizations, subcontractors and enrollees. * Monitors all formal and informal grievances with Grievance personnel to identify trends or problem areas of… more
    Molina Healthcare (08/02/25)
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  • Medical Director, Clinical Services

    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
    Highmark Health (07/29/25)
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