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Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
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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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The Grievance/Appeals Representative I is responsible for reviewing, analyzing and processing claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.
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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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Grievance and Appeals. The position of part-time Associate Medical Director is responsible for supporting the Medicare Advantage Plans clinical and quality activities and operations at the direction of the Chief Medical Officer approximately 25 hours per week.
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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. 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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Grievance/Appeals Representative I. Medicare appeals or Medicare data entry experience strongly preferred. Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
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Coordinates with other departments, e.g. Care Management, Legal Affairs, Grievance and Appeals, Compliance, Membership Eligibility Unit, Quality as needed. Knowledge of Medicaid and/or Medicare regulations required Working Knowledge of UAS-NY.
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Supports internal departments with education, and support with escalated benefit or service inquiries; internal departments to include, but not limited to; Government Programs Administration, Sales, PCSC, Enrollment, Claims, Experience Design Program, Appeals and Grievance, Health Services, Provider Network Management.
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Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues. Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.
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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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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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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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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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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. 3 to 5+ years of recent experience writing insurance appeals and pursuing Medicare for collection on behalf of hospitals (facility charges.
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grievance appeals and medicare jobs
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