- Molina Healthcare (Jacksonville, FL)
- …**Essential Job Duties** * Facilitates comprehensive research and resolution of appeals , disputes, grievances , and/or complaints from Molina members, providers, ... to work 1 Saturday a month M-F from 7am - 3 :30pm CST will require to work 1 Saturday a...internal and/or regulatory timelines are met. * Researches claims appeals and grievances using support systems to… more
- Cognizant (Tallahassee, FL)
- …or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews . ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- CVS Health (Tallahassee, FL)
- …needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. * Confer directly with providers regarding the care of ... director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals … more
- Molina Healthcare (Jacksonville, FL)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse… more
- Molina Healthcare (Jacksonville, FL)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...**I** **E** **N** **C** **E/KNOWLEDGE, SKILLS & ABILITIES:** + 3 + years relevant experience, including: + 2 years previous… more
- Molina Healthcare (FL)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- City of Jacksonville (Jacksonville, FL)
- …+ Participates in collective bargaining. + Handles labor disputes including grievances , arbitrations, unfair labor practices, and other related matters. + Reviews ... cases, hearings and at various internal board hearings and appeals . + Attends meetings of the City Council, boards,...of a Florida license to practice law. + Three ( 3 ) years of progressively responsible experience in the practice… more
- Molina Healthcare (FL)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... of health care experience, including 5 years of clinical practice experience, 3 years utilization/quality program management experience, and 2 years managed care… more
- CVS Health (Tallahassee, FL)
- …Integrated Product Experience + Experience with Part D Coverage Determination, Appeals and Grievances and/or Formulary Administration regulatory requirements and ... audit management + Experience with Part C & D reporting requirements + 3 + years serving as project lead + Adept at problem solving and decision making + Experience… more