- Sanford Health (Sioux Falls, SD)
- …governing appeals and grievance resolution. Lead and manage the end-to-end appeals and grievances process for all product lines, ensuring compliance with ... state requirements. Oversee the intake, review, resolution, and documentation of all appeals , complaints, and grievances to meet regulatory and operational… more
- AmeriHealth Caritas (Philadelphia, PA)
- …for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates + Provide support ... more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the… more
- Elevance Health (Atlanta, GA)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.... for final review and decision. + Ensures that appeals and grievances are resolved timely to… more
- Cognizant (Lincoln, NE)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews .… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... coverage review, member appeals clinical review, medical claim review, and...the investigation of potential quality of care concerns and/or grievances . * Actively support compliance functions to maintain standardized… more
- Molina Healthcare (Albuquerque, NM)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Molina Healthcare (Lincoln, NE)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- UCLA Health (Los Angeles, CA)
- …UCLA Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan. In this ... key leadership role, you'll work closely with the UHMAP Medical Director and play a vital part...Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Support day-to-day UM… more
- State of Colorado (Jefferson County, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ASSISTANT DIRECTOR OF NURSING - MID-LEVEL PROVIDER Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5120453)...Colorado. Admissions are for individuals with complex behavior and medical needs who may pose a risk to themselves… more