- Humana (Madison, WI)
- …us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments ... data requires a case by case consideration of the Medicare rules, Humana policies and medical necessity. The Medical...includes computer based review of moderately complex to complex appeals for coverage for drugs using resources outlined above… more
- CenterWell (Madison, WI)
- …and clinical policy development/implementation required + Expert knowledge of all Medicare regulations and appeals processes + Excellent analytical skills ... and appeal process. The Director, Home Health Grievances & Appeals assists members, via phone or face to face,...direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS… more
- Molina Healthcare (Racine, WI)
- …benefits (COB), subrogation and eligibility criteria. * Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory ... with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** * Facilitates comprehensive… more
- Elevance Health (Waukesha, WI)
- …Prepare and perform supervisory review of cost report reopenings. + Manage caseload of Medicare cost report Appeals + Position papers + Jurisdictional Reviews + ... member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services… more
- Elevance Health (Waukesha, WI)
- **Audit & Reimbursement II- Appeals ** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services… more
- Molina Healthcare (Madison, WI)
- …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
- Humana (Madison, WI)
- …and/or requested site of service should be authorized at the Initial and Appeals /Disputes level. All work occurs within a context of regulatory compliance, and work ... teaching conferences, and other reference sources. Medical Directors will learn Medicare , Medicaid, and Medicare Advantage requirements and will understand… more
- Humana (Madison, WI)
- …teaching conferences, and other reference sources. Medical Directors will learn Medicare , Medicare Advantage, and Medicaid requirements and will understand ... an overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient services and equipment, within their scope. The… more
- Humana (Madison, WI)
- …teaching conferences, and other reference sources. Medical Directors will learn Medicare , Medicaid, and Medicare Advantage requirements and will understand ... an overview of coding practices and clinical documentation, dispute/grievance and appeals processes, and outpatient services and equipment, within their scope.… more
- Molina Healthcare (Racine, WI)
- …issues in areas involving member/provider impact and engagement including: Appeals and Grievances, Problem Research and Resolution, and the development/maintenance ... to, phone, chat, email, and off phone work supporting our Medicaid, Medicare and/or Marketplace business. Also provides product and service information, identifies… more