- LA Care Health Plan (Los Angeles, CA)
- …required by clinical staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in meeting regulatory ... (15%) Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director , ongoing referrals and authorizations… more
- LA Care Health Plan (Los Angeles, CA)
- …consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all line of business (LOB) to identify ... This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as...the Management Team. Duties Focus on quality review of grievance and appeals cases for all LOB… more
- Humana (Sacramento, CA)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Sharp HealthCare (San Diego, CA)
- …and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) ... 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- Sharp HealthCare (San Diego, CA)
- …physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical Board of CA ... from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains benchmarked utilization… more
- Humana (Sacramento, CA)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors may join a centralized team ... of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations… more
- Humana (Sacramento, CA)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director … more
- Elevance Health (Costa Mesa, CA)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Associate Medical Director ** **Carelon Medical Benefits Management** **Radiology Benefit** **Management/Utilization** **Review** **Virtual:**… more
- LA Care Health Plan (Los Angeles, CA)
- …all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters ... required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by… more