- Cognizant (Columbus, OH)
- …. 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 (Columbus, OH)
- …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 (Columbus, OH)
- …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 (Cleveland, OH)
- …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 (Columbus, OH)
- …concurrent and prior authorization reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals in their "base plan" ... Two (2) + years of experience in managed care ( Medicare and/or Medicaid) MD or DO; Board certification in...we have an Integrated plan. Experience with managed care ( Medicare and Medicaid) utilization review preferred. **Education** MD (Doctor… more
- Humana (Columbus, OH)
- …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 (Akron, OH)
- …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
- Molina Healthcare (Cincinnati, OH)
- …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
- Molina Healthcare (Dayton, OH)
- …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
- Evolent (Columbus, OH)
- …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