- Molina Healthcare (San Antonio, TX)
- …+ Responsible for the comprehensive research and resolution of the appeals , dispute, grievances , and/or complaints from Molina members, providers ... that internal and/or regulatory timelines are met. + Research claims appeals and grievances using support systems to determine appeal and grievance outcomes. +… more
- Healthfirst (TX)
- …+ Bachelors degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization ... Reduction, Termination, and Suspension of services. The end-to-end process requires the Specialist to independently: + Research issues + Quality of Care Experience +… more
- Intermountain Health (Austin, TX)
- …the formulary transition process. + Assists Medicare and Medicaid members with grievances , coverage determination (including exceptions), and appeals process. + ... **Job Description:** The Pharmacy Government Specialist II is responsible for the day-to-day operations...call flow as well as established auditing criteria. The Specialist II stays current and conversant on general plan… more
- Healthfirst (TX)
- …including Contact Center Operations, Claims, DSE, and E&B to resolve member and provider appeals . + Ensures appeals and grievances are categorized and ... for clinical review. + Notifies team lead of identified patterns of appeals , claim errors, configuration issues or other systemic problems identified during appeal… 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 ... Provides training and guidance as needed to the Contract Managers and Contract Specialist (s). * Helps develop and utilize standardized contract templates and Pay for… more