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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.
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Must have previous Grievance and Appeals exp. Job Title:Grievance and Appeals Coordinator 1. Medical management, Utilization management, and/or running a doctor’s office.
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Capable of handling employee conflict, following grievance procedures, mediating and conflict resolution. Accomplish all daily admin tasks including running financial reports, responding to citation appeals, activating parkers off waiting lists, and any other additional tasks as they arise.
$20 an hourTemporaryExpandApply NowActive JobUpdated Yesterday - 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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Review and evaluate appeals and grievance requests to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements.
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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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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 7 days ago - UpvoteDownvoteShare Job
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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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Paralegals assist with the University’s responses to internal and external information requests, such as Public Information Act (PIA) requests; subpoenas or court/legal/administrative orders; Employee Grievance Hearings; Public Safety Denial of Access Appeals; and similar matters handled by OGC. As the need arises, Paralegals may be assigned primary responsibility for such matters.
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Monitors, trends, and analyzes grievance and appeals data for submission to appropriate parties. The Manager I - Grievance & Appeals is responsible for the management oversight of receipt, investigation and processing associated with member/provider grievance and appeals.
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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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Provides Referrals to Quality Management (QM), Disease Management, Social Services and Appeals and Grievance department (AGD). The Nurse Consultant will report to the Manager of Care Management for the Population Health Management Medi-Cal Team. In this role, you will ensure that services are provided based on standardized procedures including coordination of care with specialists and community resources.
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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. 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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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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grievance and appeals jobs
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