- LA Care Health Plan (Los Angeles, CA)
- Appeals & Grievances Regulatory Audit Readiness Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los ... verified through reconciliation of end to end on all regulatory functions. Duties Audit readiness: Performs ...Required: A minimum of 5 years of experience in regulatory auditing ( Appeals & Grievances ,… more
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA- Appeals & Grievances **Position Summary:** Appeals and Grievances Program Advisor monitors and supports the operations and compliance of the ... Appeals and Grievances department through many NCQA...audit . + Participate in data quality checks for regulatory reporting submissions by verifying data in Guiding Care… more
- VNS Health (Manhattan, NY)
- …meet our high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. * Data-Driven Decisions: Maintain the ... Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long...processes and timeframes. Maintains readiness for DOH or CMS audit at all times. + Ensures regulatory … more
- Baylor Scott & White Health (Temple, TX)
- … Appeals and Grievance Coordinator is responsible for intake into the Appeals and Grievances Department, including verbal and written complaints, ... grievances and requests for appeals that involve complex matters submitted by Members and...in writing. + Maintains required documentation to assure meeting regulatory requirements on intake processes (eg acknowledgement letters; waiver… more
- Beth Israel Lahey Health (Burlington, MA)
- …and appropriate departments. Utilize an audit tracking system (Cobius) to monitor audit processes, dollars at risk, and appeals . Provide support and training ... making a difference in people's lives.** Manages all functions of the ROI/ Audit and Research Department. Utilize technology to support ongoing efforts to protect… more
- CVS Health (Frankfort, KY)
- …every day. **Position Summary** Responsible for intake, investigation and resolution of appeals , complaints and grievances scenarios for all products, which may ... responses from multiple business units. Ensure timely, customer focused response to appeals , complaints and grievance. Identify trends and emerging issues and report… more
- Henry Ford Health System (Detroit, MI)
- …Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals . + Demonstrated experience at a professional ... GENERAL SUMMARY: Under the direction of the Compliance Audit Manager, the Principal Compliance Investigator will oversee compliance auditing and monitoring to assess… more
- Somatus (Mclean, VA)
- …Special Need Plans (SNPs). The Director, Quality will work closely with Sr. Manager, Audit Risk and the Regulatory and Accreditation Team to ensure compliance ... with audits, complaints/ grievances , and adherence to contractual obligations and Service Level...pre-delegation audits, annual client audits, development of grievance and appeals workflow processes, and other regulatory requirements.… more
- Molina Healthcare (Everett, WA)
- …to ensure appropriate reimbursement to providers. This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with ... previous claims and appeals experience. The candidate must have strong skills with...to clinical experience + Documents clinical review summaries, bill audit findings and audit details in the… more
- CHS (Clearwater, FL)
- …client trust. * Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS. Participates ... auto-adjudicated, in Examiner queues waiting to be adjudicated, and in either audit or needing approval status. * Developing and implementing strategies for greater… more