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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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May also engage in grievance and appeals reviews. 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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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 ideal candidate will be well versed in the Medicare managed care appeals and grievance process. Perform follow up on any outstanding claims, manage correspondence and requests and research denials and zero payments.
ExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. + 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 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.
RemoteExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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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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Preferred Qualifications + 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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The curiosity to learn, the flexibility to adapt and the courage to innovate Additional Information Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business.
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Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.
$45,850 - $55,500 a yearFull-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Responsibilities 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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Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it.
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Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work. Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities.
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Experience in Medicare Advantage Claims, Appeals & Grievances, program/project management. 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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grievance appeals and claims jobs
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