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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. Filing complaints and grievances through the CMS and Medicaid systems to resolve unfair payment practices and trends.
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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.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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Liaison to Services team coordinating efficient and accurate member ad provider servicing as well as Grievance and Appeals processing according to CMS requirements and regulations.
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Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member's appeal or grievance is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state or federal specific regulations that apply.
Full-timeExpandApply NowActive JobUpdated 14 days ago - UpvoteDownvoteShare Job
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Job SummaryThe Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines.
Full-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Performs oversight of the enrollment, billing, and membership operations ensuring efficient and accurate processing enrollment, maintenance and billing according to CMS requirements and regulations.
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Serves as the internal expert on CMS EM&B processing guidelines and regulations. Serves as the internal expert on CMS and BlueCross BlueShield Service processing guidelines and regulations.
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Coordinate the workflow and operations of two units within the grievance and appeals department, commercial and Government Programs. Manage the daily work of administrative grievance and appeals staff to ensure adherence to quality standards, deadlines, and proper procedures.
Full-timeExpandApply NowActive JobUpdated 15 days ago - UpvoteDownvoteShare Job
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The Business Process Services (BPS) Manager is focused on the Enrollment, Membership, and Billing (EM&B) domain and responsible for overseeing department activities ensuring efficient, accurate, and compliant operational processing.
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Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member's appeal or grievance providing further appeal options as appropriate.
Full-timeExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing. This individual prepares cases for presentation, discussion, review and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed.
Full-timeExpandApply NowActive JobUpdated 20 days ago - UpvoteDownvoteShare Job
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Minimum of four years of administrative support experience in a health care organization required Knowledge of DOH and CMS Grievance and Appeals regulatory requirements and procedures for ensuring compliance preferred Proficient PC skills, including MS Excel, Word, and Access required Knowledge of Facets system preferred.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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As an important member of our Medicare Advantage team, you will drive the development, implementation, and execution of organizational and operational strategies for claims, provider contracts, and appeals and grievance systems configuration.
$67,400 - $133,400 a yearFull-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Assist in the development of internal physician advisors and provide support in developing solutions for complex cases, in the authorization and denial of services, and in the grievance and appeals process.
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Prepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Prepares and maintains case files and database for appeals and grievances in accordance with SHP, DHS, CMS, and DMHC requirements and NCQA accreditation standards.
Full-timeRemoteExpandApply NowActive JobUpdated 8 days ago
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