- Molina Healthcare (St. Petersburg, FL)
- …including 3 years in a manager role. * Experience with Medicare Regulations, Medicare Duals, Appeals & Grievances , Provider Disputes (Par and Non-Par) ... for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that...requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures… more
- Molina Healthcare (Jacksonville, FL)
- …Summary** Responsible for leading, organizing and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance ... **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that… more
- Humana (Tallahassee, FL)
- … 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 appropriateness of services… more
- Molina Healthcare (Tampa, FL)
- …or related field (advanced degree a plus). **Experience** * 7+ years managing Medicare CTM, appeals & grievances , or related compliance functions-hands-on ... must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and...SLA tracking, and program audits. * Deep knowledge of Medicare regulations affecting complaints, grievances , and member… more
- Molina Healthcare (Orlando, FL)
- …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
- CVS Health (Tallahassee, FL)
- …oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for ... UM and participate in UM front line work and appeals in markets as needed. * Confer directly with...peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical coverage… more
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