- Humana (Albany, NY)
- …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… more
- Molina Healthcare (Yonkers, NY)
- …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
- Molina Healthcare (Rochester, NY)
- …and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with the standards and requirements established by ... and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as needed. + Ensures that ... of the Children's Behavioral Health (BH) Carve-In program. The Medical Director for BH Children's Services has...Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular… more
- Molina Healthcare (Rochester, NY)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Highmark Health (Albany, NY)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… more