- Humana (Lansing, MI)
- …responsibility for evolving Humana's Utilization Management of medical review by physician or nurse , with a focus on our 5+ million Medicare members. You will also ... : Characterize the impactable drivers of prior authorization and look at appeals rate with denials and overturns. Deliver the upmost consistent medical director… more
- CVS Health (Lansing, MI)
- …in accordance with contract. + Process claim referrals, new claim handoffs, nurse reviews, provider complaints, grievance and appeals via target system. ... + Assists providers with credentialing/re-credentialing and contracting questions and issues. + Assist in compiling claim data for audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming… more