- Molina Healthcare (WI)
- …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
- CVS Health (Madison, WI)
- …areas. Knowledge of Aetna clinical and coding policy and experience with appeals , claim review, reimbursement issues, and coding is preferable, but a willingness ... pre-certification, and predetermination of covered benefits in the commercial, Medicare , and Medicaid environment. This Wheelchair DME consultant provides subject… more
- Evolent (Madison, WI)
- …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 (Madison, WI)
- …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
- Molina Healthcare (Green Bay, WI)
- …to healthcare premium. * Assist in resolution for escalated premium issues with Appeals and Grievances team members. * Guide and collaborates with enrollment team to ... timely and accurate processing of payment received.* Marketplace, Commercial, or Medicare healthcare experience with premium billing and reconciliation. * Must have… more
- Evolent (Madison, WI)
- …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 (Madison, WI)
- …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 (Madison, WI)
- …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
- Merck (Madison, WI)
- …of patient enrollment process, payer coverage policies, prior authorization process, appeals process, patient support programs, and Hub operations to Field Access ... or reimbursement support * Strong knowledge of health insurance structures ( Medicare Part B, Medicaid, commercial) and related access processes, including benefit… more
- Highmark Health (Madison, WI)
- …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