- 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
- Elevance Health (Atlanta, GA)
- …to Medical Director for final review and decision. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external review. + Research to...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Molina Healthcare (Lincoln, NE)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Molina Healthcare (Detroit, MI)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse… more
- Commonwealth Care Alliance (Boston, MA)
- …of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the ... schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and… 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) Apply ASSISTANT DIRECTOR OF… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP)… more
- UCLA Health (Los Angeles, CA)
- …+ Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Support day-to-day UM and Clinical ... you passionate about evidence-based medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage...is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan.… more
- Molina Healthcare (Albuquerque, NM)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- State of Colorado (Grand Junction, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... Behavioral Site Director (Health Professional V) - Grand Junction Regional...staff, including hiring, training, evaluations, disciplinary actions, and resolving grievances . - Direct staff resources to ensure effective delivery… more
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