- Point32Health (FL)
- …Point32Health (https://www.point32health.org/) . **Job Summary** Under the general direction of the Member Appeals and Grievance Supervisor the Appeals and ... for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual… more
- Humana (Tallahassee, FL)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.… more
- CVS Health (Tallahassee, FL)
- …-Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. -Educates ... providers on our self-service options; Assists providers with credentialing and re-credentialing issues. -Responds to requests received from Aetna's Law Document Center regarding litigation; lawsuits. -Handles extensive file review requests.… more
- CVS Health (Tallahassee, FL)
- …contract. + Process claim referrals, new claim handoffs, nurse reviews, provider complaints, grievance and appeals via target system. + Assists providers with ... credentialing/re-credentialing and contracting questions and issues. + Assist in compiling claim data for audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal… more
- Elevance Health (Miami, FL)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... consistent use of medical policies when making medical necessity decisions. + Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation. **Minimum Requirements:** + Requires MD or DO and… more
- Humana (Tallahassee, FL)
- …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational ... committees. \#physiciancareers Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of… more
- Molina Healthcare (Miami, FL)
- …hours** Must be able to rotate weekends and holidays** Must have Medicare Appeals and IRE experience** Responsible for reviewing and resolving member and provider ... + Responsible for the comprehensive research and resolution of the appeals , dispute, grievances, and/or complaints from Molina members, providers and related… more
- Molina Healthcare (Tampa, FL)
- …Member issues in areas involving member impact and engagement including: Appeals and Grievances, Member Problem Research and Resolution, and the ... subcontractors and enrollees. * Monitors all formal and informal grievances with Grievance personnel to identify trends or problem areas of access and care… more
- Humana (Tallahassee, FL)
- …business outcomes and organizational strategy. + Track, analyze, and report on grievance , appeal, and complaint metrics to identify trends and drive continuous ... revenue. + Collaborate with peer leaders in Risk Management and Grievances & Appeals to implement best practices and ensure timely, equitable resolution of issues.… more