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Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol. Maintain working knowledge of COA and OHP benefits including physical health and behavioral health (RNCC/AI AN will maintain working knowledge of Native American Oregon Health Plan Fee For Service program benefits.
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Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly.
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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider),grievance and appeals (member/provider) via target system. 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.
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Grievance and Appeals experience. Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health PulsePoint location. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
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Handles incoming requests for appeals and preauthorization not handled by Clinical Claim Management. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.
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Adjudicate medically related grievances and appeals that flow through the Member grievance and appeals process. Develops and manages a formal Utilization Management Program for the Plan and its Providers.
$240,676.8 a yearExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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The Director is responsible for all aspects of the member appeals and grievance processes for all lines of business across the enterprise, including Commercial, Senior Products, Public Plans, joint ventures, and other state sponsored products.
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The Grievance and Appeals Coordinator will also present cases to the Appeals Committee. The Appeals and Grievance Coordinator will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare.
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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
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Provide physician leadership and clinical support for the following areas: Grievance and Appeals, Care Management, Potential Quality Issues. Provide physician leadership for UM and CM Delegation oversight activities of the Plan, including Behavioral Health.
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In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements.
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Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary. Benefits are made up of four different programs: CalPERS Pension Plan, 401A Discretionary Plan, 401A Supplemental PEPRA Plan, and an optional 457 deferred compensation plan.
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Creates an emotional connection with our members by understanding and engaging the member tothe fullest to champion for our members' best health. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence andinternal referrals.
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Health Plan Core systems i.e. Claims, Membership, Grievance and Appeals. Perfict Global is a leading IT consulting services provider focused on providing innovative and successful business workforce solutions to Fortune 500 companies.
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Applies expert knowledge of the technical aspects of the work directed (employee relations principles and practices, appeals and grievance processes, OWCP, position management, staffing, human resources concepts, and best practices) using knowledge of case laws (MSPB) and precedents, government regulations, executive orders and agency rules.
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grievance appeals and health plan jobs
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