- Molina Healthcare (Houston, TX)
- …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 (Austin, TX)
- …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 (Austin, TX)
- … 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 (Austin, TX)
- …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
- Molina Healthcare (Houston, TX)
- …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
- Guardian Life (Austin, TX)
- …compliant with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and ... The **Texas State Dental Director ** will be responsible for ensuring that professional...ensure that determination and processing of claims, referrals and appeals meet state regulations, time frames & definitions +… more
- Highmark Health (Austin, TX)
- …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 (Austin, TX)
- …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
- J&J Family of Companies (Dallas, TX)
- …such as eligibility and benefit verification, pre-authorization, billing, coding, claims, and appeals / grievances ; practice management, as well as Medicare and ... administrators, CFOs, billing and collections staff, clinical staff including pharmacy director ; Health Plans' and MCOs' Medical Directors, Case Managers, Pharmacy… more