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The Program Manager is a key member of the Medicare Advantage Claims, Configuration and Appeals and Grievance Operations team. Assists in planning, developing, implementing, and managing the Medicare Advantage Claims, Appeals and Grievance program requirements, operational initiatives and policies.
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The Program Manager leads and manages key operational programs, initiatives and strategic projects that span across the functional teams of Claims, Configuration and Appeals and Grievances.
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The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements.
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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
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May also engage in grievance and appeals reviews. Become a part of our caring community and help us put health first. Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post acute services such as inpatient rehabilitation.
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Department(s): Grievance & Appeals Resolution Services (GARS)Reports to: Manager, Grievance & AppealsSalary: $24.52 - $31.04 Duration: up to 6 months Job Summary The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions.
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Along with the Assistant Director, Medicare Advantage Operations, the Program Manager is responsible for program management activities impacting the functional areas within the span of control of the Assistant Director including but not limited to initiation, planning, development, and monitoring of program implementations and day to day operations performance monitoring in order to ensure timeliness and compliance.
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Experience in Medicare Advantage Claims, Appeals & Grievances, program/project management. The incumbent reviews and analyzes key program, regulatory and operational performance indicators for the functional areas reporting to the Assistant Director, Medicare Advantage Operations and makes recommendations to the leadership team on strategies to improve performance.
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Our client, a Medical Center facility under the aegis of a California Public Ivy university and one of largest health delivery systems in California, seeks an accomplished Medicare Program Manager.
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Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients businesses forward.
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Experience with national guidelines such as MCG or InterQual + Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization + Advanced degree such as an MBA, MHA, or MPH + Exposure to Public Health principles, Population Health, analytics, and use of business metrics.
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Medical Director - Southeast Region - Work from Home at Humana in Boise, Idaho, United States Job Description Become a part of our caring community and help us put health first The Medical Director relies on medical background and reviews health claims.
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Grievance and Appeals experience or knowledge. Humana Healthy Horizons (HHH) in Indiana is seeking a Senior Vendor Management Professional to work as the liaison between our NEMT subcontractor and the organization.
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Participates in processes related to faculty counseling, faculty grievance, and appeals related to the SON operations. It is the state’s flagship institution of higher education and includes a main campus in Storrs, CT, four regional campuses throughout the state, and 13 Schools and Colleges, including a Law School in Hartford, and Medical and Dental Schools at the UConn Health campus in Farmington.
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Experience with Microsoft Office Suite (Excel, Word, and PowerPoint) and data visualization tools. Amerit Consulting is an extremely fast-growing staffing and consulting firm. Must have knowledge and experience in project management, health plan operations, data analysis, and strong organizational, communication and leadership skills.
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