- CenterWell (Madison, WI)
- …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 (Green Bay, WI)
- …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 (Madison, WI)
- …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
- J&J Family of Companies (Milwaukee, WI)
- …assigned. + Educate HCPs on product coverage, prior authorizations and appeals , reimbursement processes, claims submissions, procedures, and coding requirements of ... access and affordability solutions across multiple payer types and plans (ie, Medicare , Medicaid Managed Care, Commercial). + Execute business in accordance with the… more
- Merck (Madison, WI)
- …HCP accounts on patient access, including benefit verification, prior authorization process, appeals process, and patient support programs in both live and virtual ... how the products are covered under the benefit design (Commercial, Medicare , Medicaid) * Answer questions about coverage, including payer-specific access questions… more
- Marshfield Clinic (Marshfield, WI)
- …Reimbursement Auditor (Remote in Wisconsin) **Cost Center:** 101651059 Coding-Audit Appeals Educ **Scheduled Weekly Hours:** 40 **Employee Type:** Regular **Work ... Common Procedure Coding System (HCPCS), and Center for Medicaid and Medicare Services (CMS) documentation and billing policies. The individual will typically… more
- Humana (Madison, WI)
- …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 (WI)
- …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
- Molina Healthcare (Racine, 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
- Centene Corporation (Madison, WI)
- …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