- Molina Healthcare (North Las Vegas, NV)
- …medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Sharecare (Carson City, NV)
- …available 3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and ... enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical,… more
- CVS Health (Carson City, NV)
- …accordance with contract. + Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) ... to incoming correspondence and internal referrals. + Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.… more
- Centene Corporation (Carson City, NV)
- …Systems), HOS (Health Outcomes Survey), CTMs (Complaints to Medicare), Disenrollments, Appeals , and Grievances. + Collaborates with Provider Relations and other ... provider facing teams to improve provider performance in Quality ( Clinical and Member Experience measures). Provides clear insight into provider group dynamics,… more