- MVP Health Care (Schenectady, NY)
- Director , Appeals and Grievances 625 State St, Schenectady, NY 12305, USA Req #2608 Friday, May 16, 2025 At MVP Health Care, we're on a mission to create a ... innovative thinking and continuous improvement. To achieve this, we're looking for a Director , Appeals & Grievances to join #TeamMVP. This is the opportunity… more
- 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
- 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
- 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
- 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 (Syracuse, 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
- 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
- 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
- City of New York (New York, NY)
- …of Correction" Investigate any matter within the jurisdiction of the Department Review grievances from person in custody and staff Evaluate the performance of the ... on areas of key correctional planning. UNIT DESCRIPTION: The Board's Executive Director (ED) oversees a 31-person staff and a $3 million annual operating… more