- Molina Healthcare (San Antonio, TX)
- **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 (TX)
- …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 (Austin, TX)
- …- **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 (San Antonio, TX)
- …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
- CVS Health (Austin, TX)
- … 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 (Austin, TX)
- …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 (Austin, TX)
- …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
- HCA Healthcare (Live Oak, TX)
- …on contracting, pricing, and analysis of managed care issues. Offers clinical support for appeals and denials process, discharge planning, case management, ... role of the Facility Chief Medical Officer (CMO) ensures high quality, patient-centered care by leading clinical and quality initiatives that support the… more
- Evolent (Austin, TX)
- …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 (Austin, TX)
- …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