- Molina Healthcare (Cincinnati, OH)
- **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
- Evolent (Columbus, OH)
- …- **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 (Akron, OH)
- …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 (Mason, OH)
- … 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 (Columbus, OH)
- … 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 (Columbus, OH)
- …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
- Humana (Columbus, OH)
- …ABMS Medical Specialty + Excellent communication skills + 5 years of established clinical experience + Knowledge of the managed care industry including Medicare, ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative… more
- Evolent (Columbus, OH)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... you ready to make a meaningful impact on patient care in a non- clinical setting? Join our...to ensure the application of best practices. + Provides clinical rationale for standard and expedited appeals .… more
- Highmark Health (Columbus, OH)
- …to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. ... DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of...or Public Health **EXPERIENCE** **Required** + 5 years in Clinical , Direct Patient care (hospital, outpatient, or… more
- Evolent (Columbus, OH)
- …of the request. + Provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... and costly health conditions. Working across specialties and primary care , we seek to connect the pieces of fragmented...Director, MSK Surgery you will be a specialty match reviewer for Spine Surgery cases. you will be a… more