• Director , Appeals…

    Molina Healthcare (Yonkers, NY)
    …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving...monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and… more
    Molina Healthcare (05/16/25)
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  • Corporate Medical Director - Medicare…

    Humana (Albany, NY)
    …Director (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 appropriateness and… more
    Humana (04/24/25)
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  • Medical Director - Medicare…

    Humana (Albany, NY)
    … 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
    Humana (05/14/25)
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  • Director , Grievance and Appeals

    Humana (Albany, NY)
    …health first** The Resolution team handles all complaints for Humana, including formal grievances , appeals , inquiries and disputes. Our mission is to resolve ... for our associates, members and providers. As the Resolution Team Operations Director ( Director , Grievance and Appeals ), you will be accountable for the… more
    Humana (05/30/25)
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  • Medical Director , Children's Services…

    Excellus BlueCross BlueShield (Buffalo, NY)
    …on the Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) ... care system. + Develops, conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as… more
    Excellus BlueCross BlueShield (05/10/25)
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  • Medical Director Specialty Medical Services…

    Molina Healthcare (New York, NY)
    …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... **JOB DESCRIPTION** **Job Summary** The Medical Director for Specialty Medical Services & Market Performance will provide clinical expertise and support to the… more
    Molina Healthcare (04/11/25)
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  • Medical Director

    Highmark Health (Albany, NY)
    …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more
    Highmark Health (05/07/25)
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  • National Contracting Director

    Molina Healthcare (New York, NY)
    …for claims payment); Provider/Member Inquiry Research and Resolution; and Provider/Member Appeals and Grievances . * Coordinates with Corporate and Business ... Development teams to ensure that Molina grows faster (profitable growth) than our competitors in target new markets and expansion opportunities. * Provides training and guidance as needed to the Contract Managers and Contract Specialist(s). * Helps develop and… more
    Molina Healthcare (04/11/25)
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  • Assistant General Counsel

    City of New York (New York, NY)
    …the Uniform Commercial Code ("UCC"); 10) assist division staff with procurement appeals and decision process, including draft opinions and presenting facts and ... to the Agency Chief Contracting Officer and agency staff; and 11) assist Director of Labor Relations, Human Resources, and others on issues pertaining agency… more
    City of New York (05/14/25)
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  • Assistant General Counsel

    City of New York (New York, NY)
    …the Uniform Commercial Code ("UCC"); 7) assist division staff with procurement appeals and decision process, including draft opinions and presenting facts and ... decisions to the Agency Chief Contracting Officer and agency staff; 8) assist Director of Labor Relations, Human Resources, and others on issues pertaining agency… more
    City of New York (05/14/25)
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