- Humana (Honolulu, HI)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The ... Corporate Medical Director works on problems of diverse scope and complexity...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Possess analysis… more
- UCLA Health (Los Angeles, CA)
- …Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Medical Director , Clinical Operations to help shape the future of our plan. ... In this key leadership role, you'll work closely with the Medical Director , Department of Health Services and play a vital part in scaling Health Services… more
- Dignity Health (Bakersfield, CA)
- …to the Medical Director of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related ... offices, primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… more
- Trinity Health (West Springfield, MA)
- …The Director , Quality Improvement and Compliance, in collaboration with the Medical Director , is responsible for developing and implementing the annual QI ... implement the annual Quality Improvement (QI) Plan with the Medical Director + In conjunction with ...compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program.… more
- Molina Healthcare (AZ)
- …corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews… more
- Commonwealth Care Alliance (Boston, MA)
- 011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider ... network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider… more
- Sanford Health (Sioux Falls, SD)
- …Shifts **Job Schedule:** Full time **Weekly Hours:** 40.00 **Job Summary** The Director of Provider Network Contracting is responsible for maintaining and growing a ... resources to ensure compliance with applicable state/federal access requirements. The Director will negotiate reimbursement terms that are built on Sanford Health… more
- State of Colorado (Pueblo, CO)
- …This position ensures compliance with nondiscrimination policies and manages grievances related to discrimination. This position manages complaints, develops ... + Review of videos involving physical response, abuse allegations, and youth grievances (if applicable). Additional reviews as required by the Youth Center… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more