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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.
$24.52 - $31.04 an hourTemporaryExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol. RN experience in home care, advanced illness, palliative care, hospice, primary care and/or case management.
$87,135 - $105,435 a yearFull-timeExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Meets performance measurement goals for Grievance and Appeals Resolution Services. Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
ExpandApply NowActive JobUpdated 11 days ago - UpvoteDownvoteShare Job
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As a member of SFHP’s the Grievance Review Committee, the QRN supports the Grievance and Appeals team in ensuring that clinical concerns are addressed as part of grievance investigations.
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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.
RemoteExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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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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Under the supervision of the Appeals and Grievance Manager, assist with soliciting non-clinical information from Participating Physical Group (PPG) and specialist concerning follow care related to care management.
$47,840 - $68,474 a yearFull-timeExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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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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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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Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
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Exposure to Public Health, Population Health, analytics, and use of business metrics. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work.
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Exposure to Public Health principles, Population Health, analytics, and use of business metrics. Satellite, cellular and microwave connection can be used only if approved by leadership. 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age.
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Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.
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The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
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Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion.
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