- Molina Healthcare (Warren, MI)
- …8am-5pm PST hours** Must be able to rotate weekends and holidays** Must have Medicare Appeals and IRE experience** Responsible for reviewing and resolving member ... subrogation, and eligibility criteria. + Familiarity with Medicaid and Medicare claims denials and appeals processing, and...with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for … more
- Humana (Lansing, MI)
- …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... established clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be passionate about… more
- Humana (Lansing, MI)
- …Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate about contributing… more
- Humana (Lansing, MI)
- …us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments ... analysis of situations or data requires a case-by-case consideration of the Medicare rules, Humana policies and medical necessity. The Medical Director's work… more
- Molina Healthcare (Ann Arbor, MI)
- …or related field (advanced degree a plus). **Experience** * 7+ years managing Medicare CTM, appeals & grievances, or related compliance functions-hands-on with ... delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances, enrollment, claims, pharmacy, and quality functions. You surface… more
- Molina Healthcare (Ann Arbor, MI)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance ... standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases in which a formal appeals… more
- Molina Healthcare (Warren, MI)
- …with the standards and requirements established by the Centers for Medicare and Medicaid. **KNOWLEDGE/SKILLS/ABILITIES** + Enters denials and requests for appeal ... systems and other available resources. + Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines. +… more
- Humana (Lansing, MI)
- …teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to ... include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The… more
- Molina Healthcare (Sterling Heights, MI)
- …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
- Integra Partners (Troy, MI)
- …CMS, health plan policies). + Review and process clinical and administrative appeals ; coordinate with Medical Director when required. + Generate and review ... environment. + Strong understanding of utilization review, authorizations, and appeals processes. + Excellent verbal/written communication and organizational skills.… more