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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. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations about appropriateness of care, and expedite cases within established criteria and contract requirements.
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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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Under the direction of the Disputes Technology & Services (DTS) practice group leader and DTS Paralegal Manager, the Energy and Environmental Regulatory Paralegal is a highly skilled, objective-oriented individual who utilizes a combination of practical experience and cutting-edge technology in a collaborative environment to provide Firm clients and attorneys with creative and cost-efficient solutions.
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Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals.
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Promote an understanding of regulatory requirements for coverage as, as well as attend key meetings related to appeals of services denied to members. Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.
$271,866 - $351,826 a yearFull-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Identifies Grievance and Appeals trends and implements process improvements as needed. Assists in the daily requests for Grievance and Appeals. Monitors the UM standards compatible with health plans, NCQA, state and federal regulatory requirements, and health plan delegation changes by conducting established monitoring audits to both clinical and non-clinical authorization requests.
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Provides management, oversight, staff training and direction for charge description master integrity, patient account charge audits, regulatory audits and appeals, underpayment recovery and denials management for the hospital and physician clinic services.
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Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
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The Senior Associate Legal Counsel will report to the Deputy General Counsel, Environment & Climate, Litigation, and Commercial Transactions and will be responsible for providing legal support and guidance on climate, environmental, and associated regulatory matters for Washington Gas. The successful candidate will have a deep understanding of environmental law and emerging climate matters as well as experience in civil, regulatory, or administrative proceedings and appeals.
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This position also requires the provision of legal advice and training to administrative and clinical staff on matters relevant to DMH's mission and operations, such as the Department's regulatory standards, guardianship and commitment law, risk management, and human rights.
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Whether drafting and arguing critical motions, or presenting arguments before the Supreme Court, our client is equipped to handle the highest stakes appeals in forums across the country. You will provide clients with the agile counsel necessary to tackle substantial, multi-layered challenges across a wide array of constitutional, statutory, and regulatory issues affecting antitrust, intellectual property, bankruptcy, employment matters, tax disputes and more.
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Voting member of Committees like Appeals, Medical Technology and Medical Policy Approval, to help inform organization’s decisions for benefit coverage. Additional functions could include prospective, concurrent, and retrospective utilization reviews including member- facing initial reviews and appeals.
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Evaluate existing sewage disposal and water treatment installations and facilities for regulatory compliance; evaluate need for expansion or replacement of treatment systems; evaluate well sites and well construction for code compliance and acceptance as domestic water supply; and test and assess public drinking water potability.
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They will engage in continuous learning and become increasingly familiar with the health plan grievance and appeals processes over time. The Junior Grievance Coordinator is a supportive member of the Grievance and Appeals team, ensuring AlohaCare members and providers of compliant, ethical, and timely resolution of their grievance or appeal.
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Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member's EOC / benefit document. Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies.
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