- Healthfirst (NY)
- …degree + Experience in clinical practice with experience in appeals & grievances , claims processing, utilization review or utilization management/case ... and Responsibilities:** + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity,… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job Category: Administrative, HR, Business Professionals Department: CSC ... Summary The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is...manner. This position will focus on quality review of non- clinical grievance and appeals cases for all… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I(Temp) Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los ... safety net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center … more
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA- Appeals & Grievances **Position Summary** Appeals and Grievances Specialist supports the Operations Department and the Appeals and ... well as externally to facilitate timely resolution of all grievances and appeals and ensures compliance with...strict deadlines. + When necessary collaborate with care teams, clinical staff, family members, and other involved in providing… more
- Martin's Point Health Care (Portland, ME)
- …has been certified as a "Great Place to Work" since 2015. Position Summary The Appeals Quality and Training Specialist supports the Appeals Department. This ... CMS Part C and Part D Organization Determinations and Grievances guidance. + Prepares files and participates in both...projects. + Independently partners with Medical Directors and other clinical support staff on appeals requiring … more
- Adecco US, Inc. (Ontario, CA)
- Adecco is assisting a local client recruiting for Clinical Appeals Representative opportunities in Ontario, CA (90% remote). This is an excellent opportunity to ... make an impact in the healthcare industry. If a Clinical Appeals Representative role sounds like something...to: + Serve as point of contact for member grievances and potential quality of care issues + Process… more
- LA Care Health Plan (Los Angeles, CA)
- …due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist .; submit all Grievances and Appeals response letters ... Authorization Technician II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID:… more
- State of Colorado (Canon City, CO)
- …plans; + Diagnose and treat dental disease of offenders or refer offenders to specialist for treatment; + This position may be required to participate in restraining ... of care; + Collaborate with other health care professionals, clinical services staff regarding offender health issue/policies, transfers, classifications and… 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 ... and compliance risks. + Provides instruction to department staff and clinical employees in correct documentation processes and coding guidelines. + Provides… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …card distribution, accurate provider directories, performance on VBC contracts, benefit adjudication, appeals , and grievances . + Collaborate with the TPA to ... the VP Pharmacy for performance on pharmaceutical spending targets, and the clinical team for population management. STRATEGICE PLANNING AND PROCESS IMPROVEMENT: +… more
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