• Coordinator Appeals & Grievances

    AmeriHealth Caritas (Philadelphia, PA)
    …more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the ... complaints/issues to management + Monitors to ensure that all problems with appeals / grievances presented by plan members/participants are resolved in accordance… more
    AmeriHealth Caritas (10/09/25)
    - Related Jobs

  • Corporate Medical Director - Medicare…

    Humana (Harrisburg, PA)
    …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)
    - Related Jobs

  • UR Registered Nurse - Clinical Appeals…

    Cognizant (Harrisburg, PA)
    …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)
    - Related Jobs

  • Part-Time Weekend Medical Director…

    Highmark Health (Harrisburg, PA)
    …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)
    - Related Jobs

  • Medical Director - Utilization Management

    UPMC (Pittsburgh, PA)
    The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
    UPMC (10/03/25)
    - Related Jobs

  • Medical Director - Utilization Management

    UPMC (Pittsburgh, PA)
    …improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care ... The Medical Director , Utilization Management is responsible for assuring physician...health care to UPMC Health Plan members. This fully remote role will be responsible for assuring physician commitment… more
    UPMC (09/11/25)
    - Related Jobs