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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.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. Filing complaints with Medicare and Medicaid agencies when claims are denied in error.
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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider),grievance and appeals (member/provider) via target system. Handles incoming requests for appeals and preauthorization not handled by Clinical Claim Management.
Full-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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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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Engages, consults, and educates membersbased upon the member’s unique needs, preferences and understanding of Aetna plans, tools, and resources to help guide he membersalong a clear path to care.
Full-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Make appeals complaints and grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness. Analyze, research, resolve and respond to complaints, appeals, and grievances from members, providers, and regulatory agencies with established regulatory and accreditation guidelines.
Full-timeExpandApply NowActive JobUpdated 2 months ago - UpvoteDownvoteShare Job
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Process telephone calls from providers, other department staff, and members/enrollees in regard to complaints, compliments, grievance procedures, denials, and appeals.
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Research and resolve grievance and appeals for the commercial line of business, utilizing a higher level of adjudicator expertise, clinical interpretation and decision making.
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Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA.
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Processes claim referrals, new claim handoffs, nurse reviews, provider complaints, and provider grievance and appeals. Work Hours - Could be scheduled between the hours of 7am to 7pm local timeRequired QualificationsFamiliarity with Microsoft Office productsExcellent computer skills using multiple screens and systems to achieve resultsExperience in highly transactional call center environmentExcellent customer service and critical thinkingThis is a fully-remote position.
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TheCSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources tocomply with any regulatory guidelines. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.
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May coordinate the Grievance and Appeals Committee. Prepare response letters for member and provider complaints, grievances and appeals. Gather, analyze and report verbal and written member and provider complaints, grievances and appeals.
Full-timeExpandUpdated 17 days ago - UpvoteDownvoteShare Job
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After training, the permanent schedule is an Monday-Friday, starting as early as 7 am CST and ending as late as 7 pm CST. Assists providers with credentialing and re-credentialing and contracting questions and issues.
$17 - $25.65 an hourFull-timeWork from homeExpandApply NowActive JobUpdated 21 days ago - UpvoteDownvoteShare Job
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Coordinates the timely completion of HDS's grievance and appeals process, including acknowledging, researching, and resolving complaints and appeals from HDS members and dentists.
$60,000 a yearExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Senior Grievance and Appeals Specialist. Knowledge of Medicare/Medicaid Grievance and appeals process. Lead investigations and responses to SDOH (State Department of Health) and CMS (Center of Medicaid and Medicare) complaints.
$31.89 - $35.88 an hourFull-timeExpandUpdated 7 days ago
grievance appeals and complaints jobs
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