- Molina Healthcare (Miami, 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 (FL)
- …assist with research. + Determines appropriate language for letters and prepare responses to appeals and grievances . + Elevates appropriate appeals to the ... systems and other available resources. + Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines. +… more
- Point32Health (FL)
- …responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for ... to organize, plan and implement the functions of Member Appeals and Grievances , maintain timelines and turnaround times to meet multiple requirements/regulations… more
- 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 (Tallahassee, FL)
- …Director (CMD) relies on medical background to review 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 regarding the appropriateness and medical necessity of services provided by other healthcare professionals in compliance with coverage… more
- Molina Healthcare (St. Petersburg, 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 (Jacksonville, FL)
- …and independent contracting, down line broker applications commissions, Broker Agent appeals / grievances , educating Brokers on plan benefits in all markets, ... Oversees the detailed process of broker commission reconciliation * Handles Broker Agent appeals / grievances . * Educates Brokers on plan benefits in all markets.… more
- Molina Healthcare (Tampa, 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
- AdventHealth (Altamonte Springs, FL)
- …and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting ... clinical denial appeals , as needed + Develops Medical Director relationships with payors to have open communication and consistently meets with these individuals to… 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