- Molina Healthcare (Tampa, FL)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of previously denied cases in which… more
- Healthfirst (FL)
- …degree + Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case ... and Responsibilities:** + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity,… more
- Evolent (Tallahassee, FL)
- …- **Required** + Minimum of 5 years in Utilization Management, health care Appeals , compliance and/or grievances/complaints in a quality improvement environment- ... to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed… more
- Molina Healthcare (Jacksonville, FL)
- …Experience. **Required Experience** * 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 ... and DRG/RCC pricing), and IPA. + 2 years supervisory/management experience with appeals /grievance and/or claims processing within a managed care setting.… more
- Elevance Health (Miami, FL)
- … and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. **How you will make an impact:** ... **Title: Grievance/ Appeals Analyst I** **Virtual:** This role enables associates...+ Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical… more
- CVS Health (Tallahassee, FL)
- … system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a ... As a Medical Director you will focus primarily on review appeal cases for denied medical services. This includes...*Two (2) or more years of experience in Health Care Delivery System eg, Clinical Practice and… more
- Humana (Tallahassee, FL)
- …practitioner issues. manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, ... appeal or further request is warranted. The Grievances & Appeals Representative 4 + Review documents +...serve to achieve their best health - delivering the care and service they need, when they need it.… more
- Humana (Tallahassee, FL)
- …health first** The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director ... and communication skills + 5 years of established, post-residency clinical experience + Knowledge of the managed care... clinical experience + Knowledge of the managed care industry including Medicare, Medicaid and/or Commercial products +… more
- CVS Health (Tallahassee, FL)
- …medical director teams focusing on inpatient care management, clinical coverage review , member appeals clinical review , medical claim review ... , and provider appeals clinical review . * Actively participate in scheduled team meetings and...Support all Clinical Quality initiatives and peer review processes including Quality of Care and… more
- HCA Healthcare (Gainesville, FL)
- …on contracting, pricing, and analysis of managed care issues. Offers clinical support for appeals and denials process, discharge planning, case management, ... Qualifications** The Facility Chief Medical Officer (CMO) ensures high quality, patient-centered care by leading clinical and quality initiatives that support… more