- Molina Healthcare (Fort Worth, TX)
- …+ 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 (Austin, TX)
- …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
- Humana (Austin, TX)
- …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 (Austin, TX)
- …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 (Fort Worth, TX)
- …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 (Dallas, TX)
- …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 (Fort Worth, TX)
- …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
- Highmark Health (Austin, TX)
- …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 (Austin, TX)
- …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 (Corpus Christi, TX)
- …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