• Specialist, Appeals & Grievances…

    Molina Healthcare (Fort Worth, TX)
    …**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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  • Clinical Registered Nurse - Utilization Management…

    Cognizant (Austin, TX)
    …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 (TX)
    …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 (Houston, TX)
    …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 (Fort Worth, TX)
    …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 (Houston, TX)
    …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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  • Senior Manager, Audit and Business Oversight

    CVS Health (Austin, TX)
    …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 (10/25/25)
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  • Principal Analytics Consultant - Medical…

    Health Care Service Corporation (Richardson, TX)
    …Job Qualifications:** + Experience with Utilization Management data (eg authorizations, appeals , grievances ) + Experience with DCMS healthcare data (eg ... claims. ICD10, DRG, APC, HCPCS, and/or CPT **This is a Flex (Hybrid) role: 3 days in office; 2 days work from home.** **Sponsorship is not available.** \#LI-PD1… more
    Health Care Service Corporation (10/16/25)
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