• Specialist, Appeals & Grievances…

    Molina Healthcare (Dayton, OH)
    …**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
    Molina Healthcare (10/26/25)
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  • Nurse Appeals

    Elevance Health (Mason, OH)
    …and forwards to Medical Director for final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + ... skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a...Experiences:** + AS or BS in Nursing preferred. + 3 years of clinical experience as a Registered Nurse… more
    Elevance Health (11/01/25)
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  • Clinical Registered Nurse - Utilization Management…

    Cognizant (Columbus, OH)
    …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
    Cognizant (10/07/25)
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  • Medical Director (NV)

    Molina Healthcare (Columbus, OH)
    …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 (10/31/25)
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  • Medical Director

    Molina Healthcare (Akron, OH)
    …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 (10/22/25)
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  • Medical Director (AZ)

    Molina Healthcare (Dayton, OH)
    …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
    Molina Healthcare (10/17/25)
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  • Advanced Practice Nurse Practitioner

    Molina Healthcare (Cleveland, OH)
    …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
    Molina Healthcare (11/01/25)
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  • REMOTE Supplemental Benefits Business Analyst

    Insight Global (Mayfield Heights, OH)
    …Authorization/Gold Carding, Eligibility/Benefits Verification, Claim Submission, Adjudication, Payment, Appeals / Grievances ) * Clear and confident communicator, ... to code from. -The company is anticipated to double in size over the next 3 years. There is a lot of opportunity and growth occurring, as well as re-evaluation… more
    Insight Global (10/31/25)
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  • Vendor Implementation Manager

    Elevance Health (Mason, OH)
    …Dental, Transportation) strongly preferred + Experience with Medicaid and Medicare grievances and appeals processes + Experience with network development ... **Required Qualifications:** + Requires a BA/BA degree and a minimum of 3 years of business analysis, process improvement, project management, network management or… more
    Elevance Health (10/29/25)
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  • Senior Manager, Audit and Business Oversight

    CVS Health (Columbus, OH)
    …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
    CVS Health (10/24/25)
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