- Cardinal Health (Doral, FL)
- …escalate issues. + Analyze denials and underpayments to determine appropriate action ( appeals , corrections, resubmissions). + Track and follow up on all submitted ... appeals until resolution. + Analyze explanation of benefits (EOBs)...claim processing and denial management preferred. + Familiarity with Medicare , Medicaid, and managed care preferred. + Proficiency in… more
- Centene Corporation (Tallahassee, FL)
- …healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the ... optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and… more
- Insight Global (Boca Raton, FL)
- …on regulations such as HIPAA, Stark Law, the Anti-Kickback Statute, Medicare /Medicaid, and third-party payor requirements; addressing AI and cybersecurity issues in ... response; and providing guidance on commercial insurance matters, including credentialing, appeals , and contracting. The role also involves drafting, reviewing, and… more
- Evolent (Tallahassee, FL)
- …of the request and provides clinical rationale for standard and expedited appeals . . Utilizes medical/clinical review guidelines and parameters to assure consistency ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . . No history of disciplinary or legal action… more
- Evolent (Tallahassee, FL)
- …subject matter expert. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls) with requesting ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . + No history of a major disciplinary or… more
- CVS Health (Tallahassee, FL)
- …Qualifications** + Pharmacist + 7-10 years work experience in healthcare + Medicare and/or Medicare -Medicaid 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… more
- Evolent (Tallahassee, FL)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/clinical review guidelines and parameters to assure consistency ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . + No history of a major disciplinary or… more
- Evolent (Tallahassee, FL)
- …of best practices. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls) with requesting physicians ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . + No history of a major disciplinary or… more
- Molina Healthcare (Miami, FL)
- …treatment * Provides second level BH clinical reviews, BH peer reviews and appeals * Supports BH committees for quality compliance. * Implements clinical practice ... State (TX) Medical License, free of sanctions from Medicaid or Medicare . **Preferred Experience** * Peer Review, medical policy/procedure development, provider… more
- Merck (Tallahassee, FL)
- …of patient enrollment process, payer coverage policies, prior authorization process, appeals process, patient support programs, and Hub operations to Field Access ... or reimbursement support * Strong knowledge of health insurance structures ( Medicare Part B, Medicaid, commercial) and related access processes, including benefit… more