- Merck (Albany, NY)
- …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 (Albany, NY)
- …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 (Buffalo, NY)
- …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
- MVP Health Care (Rochester, NY)
- …person-centered care. + Compliance & Quality: Ensure adherence to Medicaid, Medicare , and accreditation standards (eg, NCQA), including documentation and reporting. ... maintain cost-effectiveness and manage Medical Loss Ratio (MLR). + Appeals & Denials: Participate in the appeals ...+ Appeals & Denials: Participate in the appeals process for denied services and ensure timely resolution.… more
- Molina Healthcare (Yonkers, NY)
- …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
- Centene Corporation (New York, NY)
- …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
- Molina Healthcare (Rochester, NY)
- …and contractual guidelines. + Partner with provider relations, Health plans and appeals teams to address recurring dispute trends and recommend systemic solutions. + ... improvement. **Skills & Competencies** + Proven experience handling provider disputes, appeals , and overpayment recoveries in a managed care or payer environment.… more
- Evolent (Albany, NY)
- …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 (Albany, NY)
- …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
- Buffalo Hearing & Speech Center (Buffalo, NY)
- …billing as assigned individually by the accounts receivable manager. Experience in Medicare and Medicaid HMO's, Commercial payers such as ChampVA, Tricare, UHC, ... up is to be done bi-monthly on assigned controls to include corrected claims, appeals , phone calls, or provider rep assistance to assure any missing or incorrect… more