- Molina Healthcare (Cincinnati, OH)
- …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 (Mason, OH)
- …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. **Preferred Skills, Capabilities and Experiences:** + Strong preference for case… more
- Elevance Health (Mason, OH)
- …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