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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.
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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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The incumbents in this classification will have the responsibility for the preparation of appellate briefs for submission to the California Courts of Appeals and Supreme Court, as well as present oral argument to the courts as required.
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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 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 Yesterday - UpvoteDownvoteShare Job
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This position will provide legal support to the Division of Children and Family Services as a policy attorney and as a courtroom attorney for the Northern Service Area. The attorney in this position will provide legal guidance to the Children and Family Services administration on a variety of child welfare topics, including representing DHHS in administrative appeals and assisting with drafting regulations.
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Experience in Medicare Advantage Claims, Appeals & Grievances, program/project management. 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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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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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. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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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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The Office handles cases in the County’s District Courts (including Jury sessions), Juvenile Courts, and Superior Court, and is responsible for all appeals to the State Appeals Court and Massachusetts Supreme Judicial Court.
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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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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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