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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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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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Manages the relationship with both new and established vendors, including but not limited to customer service, claims processing, enrollment, medical management, credentialing and grievance and appeals.
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Maintains knowledge of grievance/appeal reporting requirements for the Office of the Center of Medicare/Medicaid Services, DHS, and Metastar. This position interfaces with the Department of Health Services (DHS), the Division of Hearings and Appeals (DHA), Ombudsman Program, the.
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May also engage in grievance and appeals reviews. 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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These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Become a part of our caring community and help us put health first.
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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.
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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 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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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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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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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.
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Other duties include, but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc.
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Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion.
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grievance appeals and medicaid jobs
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