- Dignity Health (Rancho Cordova, CA)
- **Job Summary and Responsibilities** The Appeals and Grievances LVN is a critical role responsible for managing and resolving all medical necessity appeal ... and maintaining patient confidentiality (HIPAA) are also essential. Ultimately, the Appeals and Grievances Nurse monitors denial trends, recommends corrective… more
- Dignity Health (Bakersfield, CA)
- … of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related duties. **Job Requirements** ... primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing and driving… more
- UCLA Health (Los Angeles, CA)
- Description The Assistant Director , Member Experience will work closely with the Director of Medicare Product Development & Bids to develop, lead, and execute ... to identify, analyze, and resolve root causes of member pain points and grievances + Ensure timely and effective resolution of member issues, with a focus… more
- UCLA Health (Los Angeles, CA)
- …+ Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Partner with clinical and operational ... Plan is looking for a dedicated and forward-thinking Medical Director , Clinical Operations to help shape the future of...key leadership role, you'll work closely with the Medical Director , Department of Health Services and play a vital… more
- Molina Healthcare (San Bernardino, CA)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse… more
- Highmark Health (Sacramento, CA)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
- LA Care Health Plan (Los Angeles, CA)
- …due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to ... required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by… more
- Cognizant (Sacramento, CA)
- …or clinic operations + Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews + ... + Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- City and County of San Francisco (San Francisco, CA)
- …service examination process is subject to change after adoption (eg, as a result of appeals ), as directed by the Human Resources Director or the Civil Service ... bargaining agreements. + Key duties include negotiating resolutions to grievances , investigating complaints of serious employee misconduct, and conferring with… more
- Cedars-Sinai (Beverly Hills, CA)
- …the payor + Investigates, processes and assists with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate ... no later than date of discharge. + Communicates regularly with CSMPN Medical Director , Employee Health Services, Risk Management, and TPA + Attends all CSMPN… more