- Harbor Health Services, Inc. (Mattapan, MA)
- …process improvement, communication to employees about QI efforts. Working with the Appeals and Grievances Specialist, maintains oversight of the Grievances ... consistency of decisions. Supervisory responsibilities for UM RN, Quality Analyst, Appeals and Grievances Specialist. Requirements: Bachelor's Degree required,… more
- Fallon Health (Worcester, MA)
- …of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and ... assigning all incoming appeals and grievances...for additional clerical/administrative responsibilities at the discretion of the Director or Manager. * Providing administrative assistance in support… more
- Highmark Health (Boston, MA)
- …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
- Transdev (Dorchester, MA)
- …of internal policies and procedures and regulations for accurate resolution of appeals , complaints, and grievances . + Understand legal requirements and ... The Labor Relations Manager provides support to the General Manager and Director of Human Resources on labor relations projects, priorities and issues. This… more
- Commonwealth Care Alliance (Boston, MA)
- …schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and ... will not be considered at this time._** **Position Summary:** Reporting to the Director , Claims Operations and Quality Assurance, the Claims Sr. Analyst plays a… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …(CPR) Team, the Peer Review Specialist works closely with CPR's Director and Clinical Lead, Operations Lead, Senior Credentialing Manager/ Compliance Consultant, ... subscriber certificates and apply to the investigation of member grievances . + Manage the fair hearing process for cases...to the hearing panel. + Seek CPRC Chair, CPR Director , and BCBSMA Legal Counsel approval on appropriate language… more
- Beth Israel Lahey Health (Westwood, MA)
- …address information. Escalates calls to pharmacists for clinical inquiries and escalates grievances to supervisor. 7. Maintains new and existing patient profiles and ... Support health care providers with required prior authorization and required appeals . Manage all mail/delivery of Rx orders including addressing problems/issues with… more
