- Houston Methodist (Houston, TX)
- …required to perform collections activities on complex denials and prepare complex appeals on outstanding insurance balances in the professional fee environment. This ... and serves as the subject matter expert with all payers, including Medicare , Medicaid and commercial payers, and applicable department's revenue cycle operations.… more
- CenterWell (Boston, MA)
- …teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to ... includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The… more
- UCLA Health (Los Angeles, CA)
- Description Are you passionate about evidence-based medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage Plan is looking ... guiding clinical policy that's grounded in the latest scientific research and Medicare guidelines. Your work will directly support our Health Services Department in… more
- Presbyterian Homes and Services (Roseville, MN)
- …throughout the resident's stay. + Audit RUG grouper/MDS end splits, review all expedited appeals and ALJ level appeals . Perform concurrent MDS review to assure ... for your assigned region. + Specifically communicate (but not limited to): Medicare / Medicare Advantage admissions, changes to skilled services, PPS scheduled… more
- Integra Partners (Troy, MI)
- …care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key role in collaborating ... Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program. Salary: $60,000.00/annual JOB QUALIFICATIONS:… more
- UNC Health Care (Kinston, NC)
- …the Physician Advisors and subject matter experts for all audit and appeals work activities. Assists with documentation review to support the clinical documentation ... up to date and proactive with all ongoing information, rules and regulations, Medicare and other payor regulations. 3. Reviews all denials and works collaboratively… more
- Actalent (Chattanooga, TN)
- …- Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior authorizations, pharmacy ... appeals , and member grievances focused on medications. - Performs...decision letters meet regulatory compliance Top Skills Details PharmD, Medicare Coverage, and/or Prior Authorization Experience Additional Skills &… more
- State of Massachusetts (Boston, MA)
- …senior managers regarding regulatory compliance with federal (Center for Medicare and Medicaid Services (CMS)) regulations, rules and policies;promulgation of ... technology personnel concerning federal and state criminal background checks, conducting appeals of matters related to the investigation of abuse and mistreatment,… more
- Sacramento Behavioral Healthcare Hospital (Santa Rosa, CA)
- …in a timely manner to ensure that extended stays are medically justified. + Payment Appeals : Prepare and submit appeals to third party payers in a timely manner ... and maintain appropriately detailed records of appeals . + Recordkeeping: Maintains appropriate records (AIS, UR forms/charts,...records (AIS, UR forms/charts, Peer to Peer log and Medicare forms) and substantiate activity by documentation that is… more
- CVS Health (Springfield, IL)
- …completing assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental ( Medicare /Medicaid) programs and ... Medical Director transacts Utilization Management UM activities (prior authorization and appeals ) and responds to prescriber inquiries related to UM transactions and… more