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Commercial Grievance and Appeals knowledge is highly preferred. Experience and knowledge with PEGA NextGen is highly preferred. 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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Provides Referrals to Quality Management (QM), Disease Management, Social Services and Appeals and Grievance department (AGD). The Nurse Consultant will report to the Manager of Care Management for the Population Health Management Medi-Cal Team. In this role, you will ensure that services are provided based on standardized procedures including coordination of care with specialists and community resources.
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Seek to resolve differences in accordance with the scriptural patterns summarized in the Staff Manual policy on Fair Treatment as well as the Grievance and Appeals Procedure. Be available to work 10-15 hours per week in Brock Hall during 8am and 5pm M-F.
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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.
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The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
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Location : This position will work a hybrid model (remote and office). 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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The DMEPOS Clinical Operations Associate Medical Directo r is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers pertaining to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.
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They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
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Respond to escalated provider claim inquiries received by Provider Services, Grievance and Appeals and other Departments as needed. In conjunction with the Claims Production Manager, Claims Trainer and Claims Processing Supervisors, assemble and maintain training guidelines and tools.
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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
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Manage the development of the Labor Relations staff and ensure quality service to our customers and coordinate dispute resolution programs and efforts; act as the company’s representative in the final step of the grievance and appeals procedure.
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Job Description :Clinical Operations Associate Medical DirectorCarelon Medical Benefit ManagementInterventional Pain Benefit ReviewLocation: This position will work a hybrid model (remote and office.
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Areas of oversight for this position include, but are not limited to, case management, quality management, utilization management (UM), and grievance and appeals and committee participation.
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The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
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May also engage in grievance and appeals reviews. Become a part of our caring community and help us put health first. 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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