- Molina Healthcare (Everett, WA)
- …small group of employees responsible for submission, intervention and resolution of appeals , grievances , and/or complaints from Molina members, providers and ... and provides guidance to others with respect to the more complex appeals and grievances . + Research and resolves escalated issues including state complaints and… more
- Molina Healthcare (Spokane, WA)
- …+ 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 (Bellevue, WA)
- …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
- Healthfirst (WA)
- …+ Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization ... management/case management. + Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines + Ability to work independently on several computer applications such as Microsoft Word… more
- Humana (Olympia, WA)
- …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 (Olympia, WA)
- …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
- Evolent (Olympia, WA)
- …**Required** + Minimum of 5 years in Utilization Management, health care Appeals , compliance and/or grievances /complaints in a quality improvement environment- ... culture. **What You'll Be Doing:** Job Description The Specialty Appeals Team offers candidates the opportunity to make a...part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of… more
- Molina Healthcare (Bellevue, WA)
- …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 (Vancouver, WA)
- …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 (Olympia, WA)
- …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