• Director , Appeals…

    Molina Healthcare (Yonkers, NY)
    …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 (07/20/25)
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  • 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 ... direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements… more
    Molina Healthcare (07/18/25)
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  • 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 (07/23/25)
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  • Medicare Grievances…

    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 (06/18/25)
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  • Nurse Appeals - Medicare

    Elevance Health (Latham, NY)
    …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... **Nurse Appeals - Medicare ** **Location:** Virtual: This...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
    Elevance Health (07/23/25)
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  • Director , Operational Oversight…

    Molina Healthcare (Albany, NY)
    …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 (07/13/25)
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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 (CT)

    Molina Healthcare (Albany, NY)
    …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 (07/11/25)
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