- Humana (Austin, TX)
- …for our associates, members and providers. As the Resolution Team Operations Director ( Director , Grievance and Appeals ), you will be accountable for the ... The Resolution team handles all complaints for Humana, including formal grievances, appeals , inquiries and disputes. Our mission is to resolve these complaints… more
- Molina Healthcare (Spokane, WA)
- …**Job Summary** Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and ... dispute/ appeals processing. * Establishes member and non-contracted provider grievance /dispute and appeals policies/procedures and updates annually or as… more
- Fallon Health (Worcester, MA)
- …on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** The Fallon Health (FH) Appeals and Grievance process is an essential function to FH compliance ... & Grievances Coordinator serves to administer the FH Appeals and Grievance process as outlined in...presentation of the member appeal to the FH Medical Director , Center for Medicare/Medicaid Services, contracted reviewer, as well… more
- CVS Health (Hartford, CT)
- …of this Medical Director role are related to Part C Medicare Appeals . This position is primary on the non-regulated appeals team, however the ... ABMS Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly… more
- AmeriHealth Caritas (Philadelphia, PA)
- …of medical management authorizations.; + Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial ... experience in a Managed Care environment + 1 to 3 years' experience in grievance / appeals environment required **The Ideal Person will have:** + Proven experience… more
- Humana (Jackson, MS)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Humana (Dover, DE)
- …Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within ... community and help us put health first** The Medical Director relies on medical background and reviews health claims....member population, or condition type. May also engage in grievance and appeals reviews. May participate on… more
- Sharp HealthCare (San Diego, CA)
- …and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) ... 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons License - Medical...data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources. + Achieves and maintains… more
- Guardian Life (Austin, TX)
- The **Texas State Dental Director ** will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state ... regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and...report any quality-of-care issues. In addition, the State Dental Director will be expected to lend support to the… more
- Elevance Health (Columbus, OH)
- …necessity determinations for services requested. + Makes medical necessity determinations for grievance and appeals appropriate for their specialty. + Ensures ... **Clinical Operations Medical Director ** **Medical Oncology** **Carelon Medical Benefit Management** **Virtual:**...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more