- Sanford Health (Sioux Falls, SD)
- …oversight and operational management of the organization's member and provider appeals , complaints, and grievance processes across all product lines, including ACA, ... Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures...all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution. Lead and manage the end-to-end… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …states (ME, NH, VT, MA, RI, CT) Under the general supervision of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced ... determine if an appeal is warranted. + Formulate clinical appeals and letters of medical necessity to...trends; including denials that have been escalated to the Medicare Administrative Law Judge (ALJ). + Represent DFCI at… more
- Elevance Health (Atlanta, GA)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... Appeals ** is responsible for investigating and processing and medical necessity appeals requests from members and...or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.… more
- WMCHealth (Valhalla, NY)
- …the monies lost to insurance companies due to denials. Generate appropriate appeals , both retrospective and concurrent, based on medical necessity criteria. ... Denials and Appeals Mngmt Cord Company: WMC Advanced Physician Services...change from time to time. + Review and identify medical necessity denials appropriate for appeal. + Appeal appropriate… more
- CVS Health (Sacramento, CA)
- …of covered benefits in the Commercial and Medicare environment with a focus Medicare policy., This Medical Director provides subject matter expertise in ... CVS Health company, has an outstanding opportunity for a Medical Director . Ready to take your career...of Aetna clinical and coding policy and experience with appeals , claim review, reimbursement issues, and coding is preferable,… more
- Molina Healthcare (Lincoln, NE)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Beth Israel Lahey Health (Charlestown, MA)
- …a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will perform high-level clinical ... gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in order to prove... relevant to the audits in order to prove medical necessity and level of care were warranted in… more
- CommonSpirit Health (Englewood, CO)
- …and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate ... are seeking a highly skilled individual to develop and submit clinical appeals , expertly crafting physician-aligned letters based on federal and state regulations,… more
- Molina Healthcare (Detroit, MI)
- …reviews and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… more
- Centene Corporation (Jefferson City, MO)
- …including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical ... with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including… more