• Sr Specialist, Member Engagement (Remote)

    Molina Healthcare (AZ)
    …Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances , Member Problem Research and Resolution, and the ... advocate organizations, subcontractors and enrollees. * Monitors all formal and informal grievances with Grievance personnel to identify trends or problem areas of… more
    Molina Healthcare (08/02/25)
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  • Quality Configuration Assurance Analyst III

    LA Care Health Plan (Los Angeles, CA)
    …assurance (especially related to claims, health services/population health as well as appeals and grievances systems, applications, etc.) Knowledge of and ... (including but not limited to, claims processing, population health, appeals and grievances , etc.) and the systems that support these operations. Knowledge… more
    LA Care Health Plan (08/01/25)
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  • Senior Medical Director - Sharp Health Plan…

    Sharp HealthCare (San Diego, CA)
    …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... trends in grievances . Supervises the process for identifying Potential Quality Issues. + Supervises Physician Reviewer(s) and Medical Directors including Behavioral… more
    Sharp HealthCare (07/19/25)
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  • AVP, Health Plan Operations (Connecticut)

    Molina Healthcare (Hartford, CT)
    …Management, Program Integrity, Risk Adjustment, Provider Resolution Team, Provider Appeal and Grievances , Member Appeals and Grievances , and other ... departments as required. These MHI shared services operations that support the Health Plan will have dotted line responsibility and accountability to this position. * Proactively develops, tracks, and reports to Plan leadership MHI Service Operations… more
    Molina Healthcare (06/25/25)
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  • Labor Relations Director

    Dairy Farmers of America (Kansas City, KS)
    …problems, such as working conditions, disciplinary actions, and employee and applicant appeals and grievances + Evaluate and assist with effective resolution ... of grievances and other local conflicts resulting from labor agreements + Develop and maintain effective relationships with union leadership to foster and… more
    Dairy Farmers of America (06/24/25)
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  • Medical Director - Sharp Health Plan - Hybrid…

    Sharp HealthCare (San Diego, CA)
    …policy as needed. + Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify trends ... in grievances . Supervises the process for identifying Potential Quality Issues. + Supervises Physician Reviewer(s) + Shares after-hours coverage responsibilities… more
    Sharp HealthCare (05/18/25)
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  • Labor Relations Consultant - #Staff

    Johns Hopkins University (Baltimore, MD)
    …_Record Keeping_ + Maintain the ERLR database that includes disciplinary actions, appeals , grievances , risk assessments, RFI's, and policy violations. + Updates ... the divisional employee file with accurate documentation such as signed progressive disciplinary letters. + Support the development and maintenance of ERLR employee notification and appointment template letters. **Minimum Qualifications** + Bachelor's Degree… more
    Johns Hopkins University (08/04/25)
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  • Senior Provider Engagement Network Specialist…

    Centene Corporation (Jefferson City, MO)
    …division of financial responsibility interpretation, contract rate and language interpretation, appeals , grievances and eligibility. + Serve as primary point ... of contact and liaison between assigned providers and the health plan. + Provide issue resolution support for most complex provider contracts by researching and partnering to resolve provider claims and data issues. + Act as department subject matter expert. +… more
    Centene Corporation (07/31/25)
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  • Project Manager II

    Centene Corporation (Sacramento, CA)
    …+ Prior experience with issue management in Call Center environment and/or Appeals & Grievances + Reporting knowledge **Education/Experience:** Bachelor's degree ... in related area or equivalent experience. 3+ years of project management experience. Experience working with and leading diverse groups and matrix managed environments. Proficient with project management tools, MS-Project or other project management software,… more
    Centene Corporation (07/26/25)
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  • Medicare/Medicaid Claims Reimbursement Specialist

    Commonwealth Care Alliance (Boston, MA)
    …schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and ... resolve reimbursement concerns. + Conduct retrospective audits to identify systemic payment issues and recommend resolution pathways. + Interpret and apply MassHealth fee schedules, All-Payer Rate Setting regulations, and CMS payment methodologies (eg, DRG,… more
    Commonwealth Care Alliance (05/31/25)
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