- Molina Healthcare (San Antonio, TX)
- …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
- Houston Methodist (Houston, TX)
- …internal and external financial and governmental reporting requirements. Requirements include Medicare cost reports, Federal Tax Returns Health and Human Services ... (HHS)/Centers for Medicare and Medicaid Services (CMS) reporting, Federal and State...by the fiscal inter-mediatry. Also directs re-opening requests and appeals . + Directs the coordination, review and filing of… more
- CVS Health (Austin, TX)
- …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
- Houston Methodist (Houston, TX)
- …requests for information. **SERVICE ESSENTIAL FUNCTIONS** + Prepares and submits the annual Medicare cost report for each HM hospital and assists in cost report ... amendments, audit, appeals and reopening process. + Independently prepares federal and...and keeps up-to-date with government regulations (ie Centers for Medicare and Medicaid (CMS), Internal Revenue Service (IRS), Federal… more
- Humana (Austin, TX)
- …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 (Fort Worth, TX)
- …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 (Fort Worth, TX)
- …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
- Centene Corporation (Austin, TX)
- …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 (Fort Worth, TX)
- …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
- Texas Tech University Health Sciences Center - El Paso (El Paso, TX)
- …to insurance companies in a timely manner. + Perform follow-up with Medicare , Medicaid, Medicaid, Managed Care, and Commercial insurance companies on unpaid ... vendor's queries to clarify and to complete the claim filing process. + Process appeals online or via paper submission. + Assist with billing audits and/or related… more