• Lead Specialist, Appeals & Grievances…

    Molina Healthcare (San Antonio, TX)
    …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... group of employees responsible for submission, intervention and resolution of appeals , grievances, and/or complaints from Molina members, providers and related… more
    Molina Healthcare (08/24/25)
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  • Director, Appeals & Grievances (Medicare…

    Molina Healthcare (San Antonio, TX)
    …Experience** * 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 years in a manager ... and DRG/RCC pricing), and IPA. + 2 years supervisory/management experience with appeals / grievance and/or claims processing within a managed care setting.… more
    Molina Healthcare (07/18/25)
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  • Manager, Medicare Administration

    Molina Healthcare (Fort Worth, TX)
    …procedures regarding compliance with local, state and federal guidelines. * Establishes member grievance appeals and policies and updates annually or as directed ... for Medicare and Medicaid Services. * Establishes non-contracted provider dispute and appeals policies and policies and updates annually or as directed by the… more
    Molina Healthcare (08/24/25)
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  • Medical Director - National Medicare

    Humana (Austin, TX)
    …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
    Humana (08/21/25)
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  • Utilization Management Dental Director- Texas

    Humana (Austin, TX)
    …in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews and/or condition committees. Travel: While this is ... This is accomplished by analysis and adjudication of claims, appeals , and potential quality of care issues. The Dental...o Review and resolve provider and member grievances and appeals o Provide and advance the clinical vision for… more
    Humana (08/23/25)
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  • Customer Service Representative

    CVS Health (Austin, TX)
    …-Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. -Educates ... to incoming correspondence and internal referrals. -Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. -Performs… more
    CVS Health (08/24/25)
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  • Customer Service Representative

    CVS Health (Austin, TX)
    …-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 (08/27/25)
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  • Sr. Employee Relations Advisor

    UTMB Health (Gatesville, TX)
    …disciplinary action. Provides advice and guidance to managers regarding the employee grievance and appeals processes. + Administers, interprets, communicates and ... leads training regarding various human resources policies, procedures, federal and state employment laws, and initiatives that impact the work environment to management and employees. + Serves as the employee relations expert to HR Business Partners and other… more
    UTMB Health (08/21/25)
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  • Associate Medical Director- Sleep Medicine

    Elevance Health (Houston, TX)
    …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
    Elevance Health (08/20/25)
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  • Medicaid Provider Customer Service Representative

    CVS Health (Austin, TX)
    …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
    CVS Health (08/16/25)
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