- Centene Corporation (Raleigh, NC)
- …healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the ... medical and pharmacy consultants for reviewing complex cases and medical necessity appeals . Participates in provider network development and new market expansion as… more
- University of Southern California (Arcadia, CA)
- …cost per case, excess days, resource utilization, readmission rates, denials, and appeals . + Collaborates and communicates with multidisciplinary team in all phases ... continuous improvement in both areas. + Perform 100% UR Review on all Medicare One-Day admissions. + Proactively identifies and resolves delays and obstacles to… more
- University of Rochester (Rochester, NY)
- …follow-up to obtain maximum revenue collection. Researches, corrects, resubmits claims, submits appeals and takes timely and routine action to resolve unpaid claims. ... and all audits. + Coordinates response and resolution to Medicaid and Medicare credit balances. + Requests insurance adjustments or retractions. + Reviews and… more
- Highmark Health (Buffalo, NY)
- …(URAC), Pennsylvania Department of Health, Department of Labor, the Center for Medicare and Medicaid Services (CMS) and state specific regulations. * Efficient ... timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory… more
- Elevance Health (Mason, OH)
- …weekly clinical prior authorizations and coverage determinations for Medicaid and Medicare . + Participate in the pharmaceutical care management process through ... resolve issues related to member/provider complaints, claims processing issues and appeals . **Minimum requirements:** + PharmD from an accredited school of pharmacy… more
- Commonwealth Care Alliance (Boston, MA)
- …and community supports as approved + Supports escalation of member grievances and appeals + Supports the procurement of network providers and assists in closing any ... (eCW) + Experience with disability issues preferred + Experience with Medicaid or Medicare programming and insurance products (ie ACO, MCO, PACE, or SCO) **Required… more
- Trinity Health (Fort Lauderdale, FL)
- …abstracts data and ensure charges/coding are in alignment within AMA and Medicare coding guidelines. Ensure medical documentation and coding compliance with Federal, ... Business Service (PBS) centers, including analysis of clinical documentation, assisting in appeals , root cause analysis and tracking as needed. 6. Educates clinical… more
- WellSpan Health (Chambersburg, PA)
- …account follow-up, researches claim denials for resolution and submits disputes and appeals when necessary. Represents the System in a professional manner while ... health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and… more
- WellSpan Health (York, PA)
- …account follow-up, researches claim denials for resolution and submits disputes and appeals when necessary. Represents the System in a professional manner while ... health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and… more
- Sharp HealthCare (San Diego, CA)
- …EMR.Assure correct documentation is present for 2MN benchmark and presumption.Assure Medicare Inpatient to observation status changes follow Condition Code 44 ... to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals , share findings with providers.Review all cases with readmission within 30 days;… more