- CenCal Health (Santa Barbara, CA)
- …interpretation and translation needs, alternative formats needed and intake of grievances / appeals . Hours of operation for the CareConnect Call Center ... and internal systems (eg, QNXT, MyQNXT, MEDSLite, CalSAWS, and MedHok (MHK) for grievances , appeals , authorizations and case management assistance look up and… more
- Molina Healthcare (St. Petersburg, FL)
- …including 3 years in a manager role. * Experience with Medicare Regulations, Medicare Duals, Appeals & Grievances , Provider Disputes (Par and Non-Par) ... for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that...requirements to meet contract and regulatory expectations. * Establishes Appeals & Grievances department policies and procedures… more
- Molina Healthcare (San Antonio, TX)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements… more
- Humana (Carson City, NV)
- …Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the appropriateness and… more
- Humana (Little Rock, AR)
- … Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I (Temporary) Job Category: Customer Service Department: CSC Appeals & Grievances Location: ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the...staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in… more
- Elevance Health (Tampa, FL)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... **Nurse Appeals - Medicare ** **Location:** Virtual: This...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Molina Healthcare (Tampa, FL)
- …or related field (advanced degree a plus). **Experience** * 7+ years managing Medicare CTM, appeals & grievances , or related compliance functions-hands-on ... must follow, and you keep complaint data synchronized across appeals & grievances , enrollment, claims, pharmacy, and...SLA tracking, and program audits. * Deep knowledge of Medicare regulations affecting complaints, grievances , and member… more
- Commonwealth Care Alliance (Boston, MA)
- …of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the ... schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP)… more
