- Molina Healthcare (Detroit, MI)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… more
- Molina Healthcare (Detroit, MI)
- …reviews behavioral health portions of state contracts. * Assists behavioral health medical director lead trainers in the development of enterprise-wide education ... JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health...second level behavioral health clinical reviews, peer reviews and appeals . * Supports behavioral health committees for quality compliance.… more
- Baylor Scott & White Health (Lansing, MI)
- …dashboards and reports for senior leadership, hospital senior leadership, and senior medical staff including denials from all payers, Medicare /Medicaid audit ... **Job Summary** The Director , Denial Resource Center is responsible for the...improved utilization of appropriate patient care services. Collaborates with medical , clinical, HIM and other BSWH departments to ensure… more
- Integra Partners (Troy, MI)
- …collaborating with our Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program. Salary: ... appeals and refer as needed to the Medical Director + Maintain compliance with all...in a managed care, payor environment + Experience with Medicare and Medicaid (not required, but highly desirable) +… more
- Corewell Health (Grand Rapids, MI)
- …+ Support the lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria ... payment, care management, authorizations, customer service interactions, pharmacy Rx profiles, medical policies and plan documents for Medicare product lines… more
- Cognizant (Lansing, MI)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member… more
- Integra Partners (Troy, MI)
- …InterQual, CMS, health plan policies). + Review and process clinical and administrative appeals ; coordinate with Medical Director when required. + Generate ... Medicare and Medicaid requirements. + Familiarity with DMEPOS authorization and appeals processes. + Knowledge of medical necessity criteria (InterQual, CMS,… more