- Highmark Health (Frankfort, KY)
- …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 (Lexington, KY)
- …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 (Louisville, KY)
- …relevant parties of all prior authorization determinations. + Provides resolution to grievances and appeals issues. + Responds to inquiries from physicians, ... sales team, and members related to formulary and prescription benefits. + Generates reports relating to rebates, physician utilization, Beers Criteria, Reliance members, and other ad hoc reports. + Maintains record keeping of prior authorizations, rebates, and… more
- Molina Healthcare (Morehead, KY)
- …remediate immediate and acute gaps in care and access. Assist members with filing grievances and appeals . * Connects members to CCEs, the OhioRISE Plan,or Molina ... Care Management if the members needs indicate a higher level of coordination. Provide information to members related to Molina requirements , services and benefits . * Knowledge of internal MCO processes and procedures related to Care Guide responsibilities… more