- Cognizant (Lansing, MI)
- ** Appeals & Grievance Specialist (remote)** This is a remote position open to any qualified applicant in the United States. **Job Summary:** We are seeking a ... dedicated Appeals & Grievance Specialist with 2 to...or Grievance is legitimate. A strong understanding of Claims, Appeals and Medical Benefits. Referring suspicious or… more
- Molina Healthcare (Warren, MI)
- …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 (Warren, MI)
- …for letters and prepare responses to appeals and grievances. + Elevates appropriate appeals to the Appeals Specialist . + Generates and mails denial ... systems and other available resources. + Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines. +… more
- Molina Healthcare (Ann Arbor, MI)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/ medical reviews of previously ... + Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training,… more
- Molina Healthcare (Ann Arbor, MI)
- …Advocate, Enrollment Specialist and Ombudsmen on issues of access to medical care, quality of care, enrollment and disenrollment. * Participates in HMO internal ... issues in areas involving member impact and engagement including: Appeals and Grievances, Member Problem Research and Resolution, and...internal HMO system functions that affect enrollee access to medical care and quality of care. * Serves as… more
- Cardinal Health (Lansing, MI)
- …+ Must follow through on all benefit investigation rejections, including Prior Authorizations, Appeals , etc. All avenues to obtain coverage for the product must be ... documenting patient health insurance benefit investigations, prior authorizations, and appeals , preferred + Cell/Gene therapy and/or Oncology experience, preferred +… more
- CVS Health (Lansing, MI)
- … adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies ... written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals . - Ensures all compliance requirements are satisfied and all… more
- CVS Health (Lansing, MI)
- …by using technical and claims processing expertise. + Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify ... complex non-routine Provider Refunds and Returned Checks. + Review and interpret medical contract language using provider contracts to confirm whether a claim is… more
- Trinity Health (Livonia, MI)
- …charges/coding are in alignment within AMA and Medicare coding guidelines. Ensures medical documentation and coding compliance with Federal, State and Private payer ... billing, coding and/or patient financial services. Strong working knowledge of medical terminology, data entry, supply chain processes, hospital and/or Medical… more
- Intermountain Health (Lansing, MI)
- …providers, clinical staff, compliance and the CDI team. + Audits and creates appeals for all payer and regulatory denials and downgrades and provides in-depth coding ... and billing requirements. + Demonstrates strong knowledge and understanding of medical terminology, medical acronyms, pharmacology, anatomy and physiology and… more
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