- Evolent (Madison, WI)
- …recorded in a timely and accurate manner. + May assist the Senior Medical Director in research activities/questions related to the Utilization Management ... request and provides clinical rationale for standard and expedited appeals . + Utilizes medical /clinical review guidelines and...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Molina Healthcare (Racine, WI)
- …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 (WI)
- …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
- Humana (Madison, WI)
- …and build collaborative care models in their practices + Coordinates with the Medical Director to integrate the administration and management of behavioral and ... in this role collaborates closely with Clinical Services and the Chief Medical Officer(CMO) to integrate the day-to-day administration and strategic management of… more
- Baylor Scott & White Health (Madison, WI)
- …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
- Merck (Madison, WI)
- **Job Description** Associate Director , Field Access Management The Associate Director , Field Access Management serves as the leader to a team of subject-matter ... of patient enrollment process, payer coverage policies, prior authorization process, appeals process, patient support programs, and Hub operations to Field Access… more
- Cognizant (Madison, WI)
- …. 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