- Molina Healthcare (St. Petersburg, FL)
- …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
- Molina Healthcare (Jacksonville, FL)
- …and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with the standards and requirements established by ... and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted… more
- Humana (Tallahassee, FL)
- … Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services… more
- Molina Healthcare (Tampa, FL)
- …and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and quality functions. You ... entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & Resolution you set the...Workflow Integration - Embed CTM insights into downstream operations-Stars, appeals & grievances , enrollment, claims-so each team… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage review, member… more
- Molina Healthcare (Orlando, FL)
- …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 the investigation of adverse… more
- AdventHealth (Altamonte Springs, FL)
- …and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting ... clinical denial appeals , as needed + Develops Medical Director relationships with payors to have open communication and consistently meets with these individuals… more
- University of Miami (Coral Gables, FL)
- …review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . The Director , Faculty Affairs supports the Vice Provost for ... and leading process improvement initiatives for the OFA. The Director engages with the Vice Provost for Faculty Affairs,...Assists the Vice Provost in managing salary review and appeals . + Reviews and process Coral Gables and Rosenstiel… more
- Highmark Health (Tallahassee, FL)
- …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