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Appeals and Grievance Nurse Registered Nurse II PRN. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process.
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The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process that meets state, federal, accreditation and other regulatory requirements.
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Responsible for grievance and appeals coordination and resolution for all Samaritan Health Plan (IHN, SAHP, Commercial, Choice) members who engage with the grievance process.
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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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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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Areas of oversight for this position include, but are not limited to, case management, quality management, utilization management (UM), and grievance and appeals and committee participation.
$115.71 - $159.1 an hourExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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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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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.
$40.87 - $67.82 an hourExpandUpdated 9 days ago - UpvoteDownvoteShare Job
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It is a fast-paced extremely deadline-driven department charged with processing all Termination of Tenancy (including various Tenancy related Applications to Re-open Defaults, Removal of Permanent Exclusion and Blatch), Grievance, Applicant Appeals and Trespass cases and Guardian Ad Litem (GAL) matters.
$46,231 - $69,583Full-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department. Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Residential Treatment Center, Home Health, Home Infusion, RehabProvides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease.
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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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Review Level of Care for iCare members including follow-up consultation with Grievance and Appeals or Enrollment/Eligibility/Fiscal staff. The Screener is responsible for screening members within the iCare Family Care Partnership service areas, as well as participate in all iCare and WI State LTCFS required compliance and quality assurance activities.
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Seek to resolve differences in accordance with the scriptural patterns summarized in the Staff Manual policy on Fair Treatment as well as the Grievance and Appeals Procedure. Competencies: The work-study employee will have the ability to scan documents on the copier, use email effectively, and prove competencies with Microsoft Office Suite, Adobe Acrobat, Google Apps, Canvas, and general office equipment.
(student)ExpandApply NowActive JobUpdated 6 days ago - UpvoteDownvoteShare Job
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Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our.
$22 - $33.01 an hourFull-timeExpandApply NowActive JobUpdated 24 days ago - UpvoteDownvoteShare Job
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In-depth knowledge of all aspects of managed care medical management, including UM/CM, Grievance and Appeals, medical policy, clinical claims review (professional and facility), and delegated vendor oversight.
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