- Molina Healthcare (GA)
- …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 (Columbus, GA)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and… more
- Humana (Atlanta, GA)
- …Director (CMD) relies on medical background to review 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 regarding the appropriateness and… more
- Elevance Health (Atlanta, GA)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... entities. + Utilizes leadership skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a resource for clinical and non… more
- Humana (Atlanta, GA)
- … 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 (Savannah, GA)
- …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
- Molina Healthcare (Savannah, GA)
- …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
- Highmark Health (Atlanta, GA)
- …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
- State of Georgia (Dekalb County, GA)
- …+ Compiles program statistics. + Participates in the resolution to academic student grievances and the appeal processes (grade appeals ). + Elevates faculty ... absences, student grievances and appeals , and other matters to AVPAA when warranted. +...as an assistant or associate dean, dean, or program chair/ director is preferred. Master's degree *and* Three (3) years… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …card distribution, accurate provider directories, performance on VBC contracts, benefit adjudication, appeals , and grievances . + Collaborate with the TPA to ... corrective action plans. FINANCIAL MANAGEMENT: + In conjunction with Sr. Director , Finance, oversee financial performance, manage budget and costs, and identify… more
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