- CDPHP (Albany, NY)
- …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage ... appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting… more
- Healthfirst (PA)
- …OR Dental Hygienist Preferred Qualifications: + Bachelors degree + Experience in clinical practice with experience in appeals & grievances, claims processing, ... and Responsibilities:** + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity,… more
- Elevance Health (Chicago, IL)
- **Referral Specialist I** **Location:** This position is on-site 5 days per week at **8600 Bryn Mawr Ave., St. 800, Chicago, IL 60631.** **Hours:** Monday - Friday, ... 10:30am - 7:00 pm CST. The **Referral Specialist I** is responsible for providing support to... I** is responsible for providing support to a clinical team in order to facilitate the administrative components… more
- Genesis Healthcare (PA)
- …with our Clinicians in Action professional development program. Responsibilities The Denials and Appeals Specialist is responsible for the follow up of denied ... Part-Time team members. + **Support for New Grads & Clinical Fellows:** Our Powerback Clinical Mentorship Program...response from the payer and takes appropriate action, including appeals , based on the type of denial. Documents all… more
- Molina Healthcare (Tacoma, WA)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... weekend per business need) Unrestricted RN licensure **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews… more
- Molina Healthcare (Covington, KY)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of previously denied cases in which… more
- Catholic Health (Buffalo, NY)
- …potential Summary: This position is accountable for carrying out and documenting the appeals process for denied claims denied due to reasons including, but not ... limited to clinical documentation/support for diagnostic related grouping (DRG) assignment, inpatient...third party payers in scenarios related to denials and appeals . This position educates all members of the patient… more
- Independent Health (Buffalo, NY)
- …coding guidelines and financial policies/contracts. + Responsible for all reconsideration clinical appeals to include review of records, consultation with ... and a culture that fosters growth, innovation and collaboration. **Overview** The Clinical & Coding Specialist -Senior will be responsible for reviewing coding… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …through our Healthsource blog: https://healthsource.premera.com/ . The **Medical Policy (MP) Clinical Specialist ** is a critical role in Premera, responsible ... with utilization management (UM) to promote usability. The MP Clinical Specialist monitors and updates policies associated...and other sources. + Liaise with Utilization Management and Clinical Appeals Departments to regularly review data… more