- Molina Healthcare (Bowling Green, KY)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- CVS Health (Frankfort, KY)
- …8a-5p in time zone of residence **Monday - Friday.** **Position Summary** The Appeals Nurse Consultant position is responsible for processing the medical ... necessity of Medicare appeals for participating providers. Primary duties may include, but...+ Managed Care experience + Utilization Management experience + Appeals experience + Pre Certification experience + Pre Authorization… more
- Evolent (Frankfort, KY)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a meaningful impact ... as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to… more
- Evolent (Frankfort, KY)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Molina Healthcare (Covington, KY)
- …resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training and support to clinical peers. + ... Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol. **JOB QUALIFICATIONS** Graduate from an Accredited School of Nursing **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + Minimum 3 years… more
- Molina Healthcare (Lexington, KY)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... 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 (KY)
- …medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse ... and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends… more
- Sharecare (Frankfort, KY)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- BrightSpring Health Services (Louisville, KY)
- …issues. Refer all unresolved issues to the next level including grievance and appeals . + Actively market plan to new senior care partners within plan Service ... needs and provide preventive, coordinated, and quality healthcare. With a dedicated nurse practitioner leading a personalized care plan, we strive to improve the… more