- J&J Family of Companies (Jacksonville, FL)
- …eligibility and benefit verification, pre-authorization, billing, coding, claims, and appeals /grievances); REMs certification; Medicare and Medicaid rules and ... regulations; and state-specific clinical staff licensing / certification requirements for product administration and monitoring. + Educate staff on payer requirements, coding, billing, claim submission, and acquisition. + Share TC insights with coalition… more
- Cognizant (Tallahassee, FL)
- …. Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes. ... Director based on the review of clinical documentation in accordance with Medicare , Medicaid, and third-party guidelines. . Effectively document and log claims/… more
- Cardinal Health (Tallahassee, FL)
- …and evaluating strategic opportunities for all lines of business including Medicare , Medicaid, and various commercial markets. Key responsibilities include managing ... with stakeholders like pharmacies and PSAO leadership, and improving the MAC appeals process. This role is critical for ensuring fair pricing and adherence… more
- CenterWell (Tallahassee, FL)
- …teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to ... includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The… more
- Molina Healthcare (Tampa, FL)
- …medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse ... medical director, and quality improvement staff. + Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews quality referred… more
- CVS Health (Tallahassee, FL)
- …oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for ... UM and participate in UM front line work and appeals in markets as needed. * Confer directly with...focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider … more
- Merck (Tallahassee, FL)
- …HCP accounts on patient access, including benefit verification, prior authorization process, appeals process, and patient support programs in both live and virtual ... how the products are covered under the benefit design (Commercial, Medicare , Medicaid) * Answer questions about coverage, including payer-specific access questions… more
- Humana (Tallahassee, FL)
- …to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc. ... **Preferred Qualifications** + Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical… more
- Molina Healthcare (Orlando, FL)
- …National Committee of Quality Assurance (NCQA) guidelines, and Centers for Medicare and Medicaid Services (CMS) standards. * Provides coordination and processing ... of pharmacy prior authorization requests and/or appeals . * Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other… more
- Molina Healthcare (Jacksonville, FL)
- …medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse ... clinical leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews quality… more