• Analyst, Client Analytics

    Evolent (Madison, WI)
    …supporting Evolent's clinical services (ie, specialty care, utilization management, care management, appeals & grievances ) + Using analytical tools to integrate ... various data sources to solve challenging analytical problems that align with key strategic objectives. + Developing reports that assess the value of our clinical programs or create monitoring tools to identify members with complex health needs. + Partnering… more
    Evolent (10/15/25)
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  • Family Health Advocate - Remote

    Sharecare (Madison, WI)
    …open enrollment / new hire plan selection, claims issues, ID card issues, grievances / appeals , utilization management (UM) status, including but not limited to ... with providers, payers or 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex pharmacy… more
    Sharecare (10/14/25)
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  • Medical Director, Medical Management

    Highmark Health (Madison, WI)
    …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
    Highmark Health (10/28/25)
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  • Pharmacy Coordinator

    Highmark Health (Madison, WI)
    …through paid clams review. + Participate as pharmacy representative in onsite member appeals and grievances sessions. + Serve as a resource for technical ... staff. + Other duties as assigned or requested. **QUALIFICATIONS:** **Minimum** + High school diploma or GED + Experience in pharmacy prescription claims processing/submission/payment. **Preferred** + Associate degree + Pharmacy technician certification… more
    Highmark Health (10/16/25)
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  • Medical Director (Medicare)

    Molina Healthcare (Milwaukee, WI)
    …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 investigation of adverse… more
    Molina Healthcare (10/29/25)
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  • Medical Director

    Molina Healthcare (Racine, WI)
    …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
    Molina Healthcare (10/22/25)
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  • Medical Director (AZ)

    Molina Healthcare (Green Bay, WI)
    …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
    Molina Healthcare (10/17/25)
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  • Clinical Quality Auditor Lead

    Elevance Health (Waukesha, WI)
    …guidelines. + Responsible for specific QM processes/ functions (ie compliance, grievances / appeals or HEDIS/quality improvement projects). + Assists manager with ... day-to-day monitoring and prioritizing of workflows and activities. + Develops and improves departmental processes and operations. + Monitors goals, performance and processes. + Assists with issues of non-compliance. + Mentors and coaches staff. + Trains new… more
    Elevance Health (10/30/25)
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  • LTSS Service Coordinator

    Elevance Health (Sparta, WI)
    …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:** + BA/BS degree field of study in… more
    Elevance Health (10/23/25)
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