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Extensive knowledge of Medicare Managed Care organization determination, appeals and grievance requirements, specifically reconsideration and IRE submission requirements. Demonstrate understanding of the appeals and grievance processes, including all regulatory and reporting requirements.
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A trusted client of Randstad's has an immediate opening for an experienced Grievance and Appeals Coordinator. Must be experienced with grievance and appeals, claim denials, medical terminology and CPT codes.
$19.99 - $20 an hourFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Appeals and Grievance Nurse Registered Nurse - Tyler. 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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Provider Services Grievance and Appeals. The Grievance and Appeals (G&A) Customer Service representative will oversee the Gainwell Grievance and Appeals team for our Ohio Department of Medicaid client.
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Oversees the Member Appeals and Grievance process; completes analytics to identify trends; and executes strategies to improve member satisfaction. Serves alongside the VP, Health Plan Operations as liaison for MHI Operations, including: Claims, Configuration Information Management, Provider Data Management, Credentialing, Enrollment, and Contact Center Operations.
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5 plus years’ experience in managed care including appeals and grievance and/or compliance. Acts as subject matter expert to internal departments and delegated vendors to assure all are educated and complaint with requirements of appeals and grievance regulations and processing.
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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. May also engage in grievance and appeals reviews.
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Responsible for formulating/implementing and executing all processes, requests, workflow, or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with Appeals and Grievance Manager or managed effectively.
$71,188.89 - $80,087.5 a yearFull-timeExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Inform nurses of a new case received from Grievance and Appeals Specialist. Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file.
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Provide support to Medicaid markets within the region, aiding in case review, peer to peer and appeals as needed. Become a part of our caring community and help us put health first. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.
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The clinical scenarios predominantly arise from inpatient or post-acute care environments. Provide thought leadership and consulting expertise on population health management approaches and metrics specific to the senior population with a strong lens on intersecting behavioral and social health needs.
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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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Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
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Assist the clinical pharmacist with grievance and appeals preparations as needed. Assist the clinical pharmacist with grievance and appeals preparations as needed. Identify when to escalate concerns to the clinical pharmacist or pharmacy director when there is uncertainty or barriers to addressing a situation.
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Manage student conduct, appeals, and grievance processes. The Department Chair collaborates with other departments including the Office of the Provost, Faculty Human Resources, Curriculum and Assessment, Instructional Design, Trefry Library, Electronic Course Materials, and the Center for Teaching and Learning, as well as operational departments such as Advising, Registrar, Marketing, Enterprise Data Office, Workforce Learning Solutions, and Military and Corporate Outreach.
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