- 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 (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
- 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 (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 (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
- Elevance Health (Grand Prairie, 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
- Humana (Austin, TX)
- …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
- UTMB Health (Galveston, TX)
- …action. Provides advice and guidance to managers regarding the employee grievance and appeals processes. + Administers, interprets, communicates, and ... leads training regarding various human resourcespolicies, 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
- Molina Healthcare (Fort Worth, TX)
- …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 (Fort Worth, TX)
- …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