- Humana (San Juan, PR)
- …experiences **Preferred Qualifications** + Associate's or Bachelor's Degree + Prior experience with Medicare + 1+ years of grievances and appeals experience + ... and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by...to a better quality of life for people with Medicare , Medicaid, families, individuals, military service personnel, and communities… more
- US Tech Solutions (May, OK)
- …authorizations. **Responsibilities:** + Ensure accuracy of case setup and clinical review of Medicare appeals cases. + Review internal notes or fax requests ... for clinical information to decision cases + Utilize work instructions and Medicare guidelines for accurate case processing. + Comply with CMS mandated timelines… more
- NHS Management, LLC (Tuscaloosa, AL)
- …Assists the Director of Medicare and Rehabilitation in gathering information for Medicare and Medicaid appeals and denials as requested. + During facility ... well as Company policy and procedure Directs the MDS assessment and Medicare related activities of the assigned facilities, ensuring accurate and timely assessments… more
- Mohawk Valley Health System (Utica, NY)
- …clinical variability throughout the medical staff. + Assist case managers with Medicare and Medicaid appeals and Administrative Law Judge (ALJ) testimonies. ... prevent denials or carved out days when appropriate. Provide telephonic and written appeals as requested for commercial payors. + Perform reviews and appeals .… more
- Molina Healthcare (Austin, TX)
- …to provide quality and cost-effective member care. The candidate must have Medicare Appeals and/or Utilization Management knowledge. Work hours are Monday-Friday ... 8:00am- 5:00pm PST. This position included rotating weekends and holidays is required. Remote position **Essential Job Duties** * Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and… more
- Centene Corporation (Austin, TX)
- …Providers and Systems), HOS (Health Outcomes Survey), CTMs (Complaints to Medicare ), Disenrollments, Appeals , and Grievances. + Collaborates with Provider ... enhances and maintains provider relationship across all product lines ( Medicare , Medicaid, Ambetter). Supports the development and implementation of quality… more
- Centene Corporation (Little Rock, AR)
- …Providers and Systems), HOS (Health Outcomes Survey), CTMs (Complaints to Medicare ), Disenrollments, Appeals , and Grievances. Collaborates with Provider ... enhances and maintains provider relationship across all product lines ( Medicare , Medicaid, Ambetter). Supports the development and implementation of quality… more
- General Dynamics Information Technology (Fairfax, VA)
- …on a **Development Engineer** **Lead** joining our team to assist the Office of Medicare Hearings and Appeals (OMHA) in managing its appeals workloads. ... As a **Development Engineer Lead** , you will guide the design, development, and delivery of innovative software solutions that support mission-critical operations. You'll mentor team members, shape technical strategy, and ensure high-quality, scalable… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances Location: Los ... required to achieve that purpose. Job Summary The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is...LA Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of… more
- Sanford Health (Sioux Falls, SD)
- …oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, including ACA, ... Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures...all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end… more