- 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
- Molina Healthcare (St. Petersburg, FL)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Elevance Health (Pinellas Park, FL)
- …Law Enforcement). + Assists and participates in appeal or fair hearings, member grievances , appeals , and state audits. **Minimum Requirements:** + Requires BA/BS ... degree and a minimum of 2 years of experience working with a social work agency; or any combination of education and experience which would provide an equivalent background. + Specific education, years, and type of experience may be required based upon state… more
- Humana (Tallahassee, FL)
- …$300M in annual revenue. + Collaborate with peer leaders in Risk Management and Grievances & Appeals to implement best practices and ensure timely, equitable ... resolution of issues. **Use your skills to make an impact** **Required Qualifications** + Bachelor's degree + 10 plus years' experience in health insurance operations, complaint management, and CMS STARs programs (experience in large national insurers strongly… more
- CHS (Clearwater, FL)
- …client trust. * Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS. Participates ... in Product Development and Sales processes, including participation when requested in prospective client presentations, regulatory reviews and contracting of vendors. **Primary Performance Expectations:** Performance review for the Claims Manager is ongoing,… more
- University of Miami (Coral Gables, FL)
- …Retired Faculty. + Assists the Vice Provost in managing salary review and appeals . + Reviews and process Coral Gables and Rosenstiel Schools requests for courtesy ... and directing them to the appropriate investigative unit; responsible for reviewing grievances in partnership with the Vice Provost and for planning, conducting, and… more
- City of Jacksonville (Jacksonville, FL)
- …+ Participates in collective bargaining. + Handles labor disputes including grievances , arbitrations, unfair labor practices, and other related matters. + Reviews ... Counsel (OGC) in cases, hearings and at various internal board hearings and appeals . + Attends meetings of the City Council, boards, agencies and OGC clients.… more