• Corporate Medical Director - Medicare…

    Humana (Boston, MA)
    …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
    Humana (09/05/25)
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  • UR Registered Nurse - Clinical Appeals…

    Cognizant (Boston, MA)
    …or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews . ... **Schedule:** Monday to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work… more
    Cognizant (10/09/25)
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  • Part-Time Weekend Medical Director…

    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
    Highmark Health (09/11/25)
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  • Medicare/Medicaid Claims Reimbursement Specialist

    Commonwealth Care Alliance (Boston, MA)
    …schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and ... 011250 CCA-Claims **_This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this… more
    Commonwealth Care Alliance (08/31/25)
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