- Evolent (Columbus, OH)
- …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 (Columbus, OH)
- …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 (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 a major disciplinary or… more
- Evolent (Columbus, OH)
- …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 (Dayton, OH)
- …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
- Highmark Health (Columbus, OH)
- …through paid clams review. + Participate as pharmacy representative in onsite member appeals and grievances sessions. + Serve as a resource for technical staff. + ... offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being… more
- Elevance Health (Mason, OH)
- …offices and ensures compliance with all Medicaid, Commercial, and Medicare requirements; informs relevant parties of all prior authorization determinations. ... support other lower level pharm techs. + Provides resolution to grievances and appeals issues. Responds to inquiries from physicians, sales team, and members related… more
- Cognizant (Columbus, OH)
- …billing, with strong knowledge of RARC and CARC codes. . Expertise in Medicare , Medicaid, Managed Care, and Commercial payer processes. . Deep understanding of ... reporting. . Excellent verbal and written communication skills for documentation and appeals . . Ability to meet productivity and quality standards in a fast-paced… more
- Molina Healthcare (OH)
- …* Provides second level behavioral health clinical reviews, peer reviews and appeals . * Supports behavioral health committees for quality compliance. * Implements ... compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). * Assists with the recruitment and orientation… more
- Elevance Health (Mason, OH)
- …authorization requests from physicians offices and ensures compliance with Medicare requirements; informs relevant parties of all prior authorization determinations. ... + Provides resolution to grievances and appeals issues. + Responds to inquiries from physicians, sales team, and members related to formulary and prescription… more