- Humana (Little Rock, AR)
- …Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse ... scope and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the… more
- Molina Healthcare (St. Petersburg, FL)
- …apply state level requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures in line with ... and interprets trends and prepares reports that identify root causes for Appeals , Grievances , and Provider Disputes. Recommends and implements process… more
- Molina Healthcare (Des Moines, IA)
- …and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with the standards and requirements established by ... and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted… more
- Humana (Frankfort, KY)
- … (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the… more
- UPMC (Pittsburgh, PA)
- …seeking a board-certified physician with a Pennsylvania Medical License for a Medical Director , Grievances role with UPMC Community Health Choices. This ... able to choose their weekly availability within the aforementioned time frame. The Medical Director , Grievances is responsible for assuring physician… more
- Fallon Health (Worcester, MA)
- …of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and ... assigning all incoming appeals and grievances...* Identifying the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver… more
- Elevance Health (Norfolk, VA)
- …Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are ... for medical necessity. + Extrapolates and summarizes medical information for medical director ,...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… 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
- Excellus BlueCross BlueShield (Buffalo, NY)
- …conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as needed. + Ensures that ... of the Children's Behavioral Health (BH) Carve-In program. The Medical Director for BH Children's Services has...Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular… 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
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