• Clinical Appeals Reviewer

    AmeriHealth Caritas (Philadelphia, PA)
    **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
    AmeriHealth Caritas (10/13/25)
    - Related Jobs
  • Registered Nurse - Clinical Appeals

    Cognizant (Harrisburg, PA)
    …, and retro-authorization as well as timely filing deadlines and processes. . Review clinical denials including but not limited to referral, preauthorization, ... cycle or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews .… more
    Cognizant (10/09/25)
    - Related Jobs
  • Appeals Nurse

    Evolent (Harrisburg, PA)
    …to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators… more
    Evolent (10/11/25)
    - Related Jobs
  • Senior Coordinator, Complaint & Appeals

    CVS Health (Harrisburg, PA)
    …to determine the accuracy and appropriateness of a benefit/administrative denial. * Can review a clinical determination and understand rationale for decision. * ... issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from… more
    CVS Health (10/11/25)
    - Related Jobs
  • Grievances and Appeals 3

    CenterWell (Harrisburg, PA)
    …Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, ... clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require… more
    CenterWell (10/08/25)
    - Related Jobs
  • IRT Appeals Representative

    Humana (Harrisburg, PA)
    **Become a part of our caring community and help us put health first** The Appeals Representative 4 - IRT (Internal Review Team) Investigates and resolves member ... client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if...if an appeal or further request is warranted. The Appeals Representative 4 IRT (Internal Review Team)… more
    Humana (10/10/25)
    - Related Jobs
  • RN Case Manager (Part Time) - West Penn Hospital

    Highmark Health (Pittsburgh, PA)
    …and contractual requirements. + Documents, monitors, intervenes/resolves and reports clinical denials/ appeals and retrospective payer audit denials. ... outcomes. Interviews and collects patient specified data and chart review related to readmission. + Knowledgeable of and complies...lieu of a degree + 3 years in a clinical nursing role + Current State of PA RN… more
    Highmark Health (09/13/25)
    - Related Jobs
  • Coding Appeals Specialist

    St. Luke's University Health Network (Allentown, PA)
    …regardless of a patient's ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis ... Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that… more
    St. Luke's University Health Network (10/07/25)
    - Related Jobs
  • Medical Director - Medicare Grievances…

    Humana (Harrisburg, PA)
    …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative… more
    Humana (10/02/25)
    - Related Jobs
  • Corporate Medical Director - Medicare Grievances…

    Humana (Harrisburg, PA)
    …health first** The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director ... CMD represents Humana at Administrative Law Judge hearings; exercises independent clinical judgment and decision making on complex issues regarding job duties… more
    Humana (09/05/25)
    - Related Jobs