- Molina Healthcare (Buffalo, 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
- 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 (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
- 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
- Excellus BlueCross BlueShield (Rochester, NY)
- …multiple areas, including but not limited to UM and CM, Fair Hearings and Appeals / Grievances , within three months of working in position. + Demonstrates ability ... May be required to attend Fair Hearings with Medical Director relating to specific cases. + Works independently, as...paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the Excellus… more