- 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
- US Tech Solutions (TX)
- …for this position. **Skills:** + MUST HAVE MANAGED CARE exp and Medicare /Medicaid knowledge. + MUST HAVE 6 months of experienced with Prior Authorization(required). ... + MUST HAVE experience with Medicare Part D + Must Have Pharmacy Benefit Management...have experience in handling calls regarding prior authorization and appeals ? **About US Tech Solutions:** US Tech Solutions is… more
- Abbott (Plano, TX)
- …review department to obtain appropriate authorizations. + Assist with appeals processes as and when necessary. **Required** **Qualifications** + Associates ... + General knowledge of private insurance, Worker's Compensation and Medicare guidelines pertaining to Prospective and Retrospective Utilization Review. Some… more
- Evolent (Austin, TX)
- …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 (Austin, TX)
- …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
- Houston Methodist (Houston, TX)
- …FUNCTIONS** + Assists the department in distributing required notices, including the Medicare Notice of Discharge to patients, securing signatures on the form from ... and answering questions regarding the appeal process + Distributes the Medicare Notice of Discharges to identified patients, including capturing patient and… more
- CVS Health (Austin, TX)
- …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 (Austin, TX)
- …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 (Austin, TX)
- …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