- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... and serves as a resource for associates within the Clinical Appeals and Analysis unit. We are...appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and… more
- Centene Corporation (Salem, OR)
- …that all appeal letters generated comply with both State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized ... a current RN or LPN** **Oregon state license **Utilization review , case management, and appeals experience in...report verbal and written information regarding member and provider clinical appeals , including information follow up +… more
- Molina Healthcare (Salt Lake City, UT)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- 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
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- CommonSpirit Health (Centennial, CO)
- …to help you flourish and leaders who care about your success. The RN Clinical Denials Appeals Specialist functions as a revenue management liaison for all ... as a Registered Nurse. 3 years with progressive experience in utilization review , preferred. Prior experience writing clinical denial appeal letters required.… more
- LA Care Health Plan (Los Angeles, CA)
- …(A&G) & General Operations ( Clinical ) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances ... for accuracy, clarity, and cultural appropriateness and sensitivity. + Review and monitor procedures for identifying quality of care...appeals & grievance process. Create a best in clinical appeals process that is efficient and… more
- LA Care Health Plan (Los Angeles, CA)
- …in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical... unit. This position is responsible for the quality review of complex and/or escalated clinical A&G… more
- CVS Health (Hartford, CT)
- …it all with heart, each and every day. **Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and ... active and unrestricted RN licensure in state of residence * 3+ years clinical experience **Preferred Qualifications** * Appeals Experience * Managed Care… more
- McLaren Health Care (Grand Blanc, MI)
- …of the patient care team. Educates health team colleagues about complex clinical appeals /denials, utilization review , including role, responsibilities tools, ... of accepting position. + Three years of recent denial management, case management, clinical documentation, or utilization review experience + Five years of … more
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