- Humana (Madison, WI)
- …first** The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals. The Corporate Medical Director works on ... clinical experience + Knowledge of the managed care industry including Medicare , Medicaid and/or Commercial products + Must be passionate about contributing… more
- Molina Healthcare (Madison, WI)
- …Enrollment activities (along with other Core Ops areas of responsibilities) within Medicare and Medicaid. Role is predicated on building relationships with vendors, ... Level Agreements between the parties. **Job Duties** + Develops Medicare and Medicaid vendor strategies aligned with CMS and...for additional vendor funding as required. + Oversee the review , reconciliation, and approval of invoices for payment of… more
- Molina Healthcare (Madison, WI)
- …and expertise in the performance of prior authorization, inpatient concurrent review , discharge planning, case management and interdisciplinary care team activities. ... Medical Directors + Develops medical policies and procedures + Conducts peer review **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** * Doctorate Degree in Medicine *… more
- Molina Healthcare (Kenosha, WI)
- …and/or pharmacy internal monitors who support processes involved with the review of non-formulary drugs or other drugs requiring prior authorization. + ... speed to answer, and average hold time are compliant with Centers for Medicare and Medicaid Services (CMS) regulations. + Ensures that adequate staffing coverage is… more
- Molina Healthcare (Madison, WI)
- …internal compliance program, including annual, periodic, focal, etc. audits. * Request, review and perform oversight of internal corrective action plans (CAPs) for ... it relates to the finding. * Performs support via review and approval for Corporate Operations policies, procedures, guidelines...years or more + 5 years of experience in Medicare , DSNP and CSNP population, Enrollment, A&G, Claims, Compliance,… more
- CVS Health (Madison, WI)
- …to members and providers. As a Medical Director you will focus primarily on review appeal cases for denied medical services. This includes First Level Appeals / ... Second Level Appeals / Expedited Appeals / Appeal Hearings / Special Projects and Committee participation when needed. The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary. The… more
- Evolent (Madison, WI)
- …for the culture. **What You'll Be Doing:** **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready to make a meaningful impact ... reviews for cardiovascular cases, serving as a specialty-matched expert reviewer for invasive/interventional cardiology cases (eg, cardiac catheterizations, coronary… more
- Evolent (Madison, WI)
- …Reviewers. **What You Will Be Doing:** + Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity ... the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Madison, WI)
- …or required. **What You Will Be Doing:** + Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity ... rationale for standard and expedited appeals. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Madison, WI)
- …or required. **What You Will Be Doing:** . Serve as the Physician match reviewer in Advanced Imaging cases, that do not initially meet the applicable medical ... rationale for standard and expedited appeals. . Utilizes medical/clinical review guidelines and parameters to assure consistency in the...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more