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Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for Oversight of processes related to resolution of grievance scenarios for all Medicare products, which may contain multiple issues and may require coordination of responses from multiple business units.
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This position expected to provide excellent customer service to all incoming/outgoing callers and answer and document inquiries related to dental benefits , eligibility, provider information, claims, pre-estimates/pre-authorizations, grievance and appeals, fulfillment requests and other miscellaneous inquiries.
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5 plus years’ experience in managed care including appeals and grievance and/or compliance. Acts as subject matter expert to internal departments and delegated vendors to assure all are educated and complaint with requirements of appeals and grievance regulations and processing.
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Manage student conduct, appeals, and grievance processes. The Department Chair collaborates with other departments including the Office of the Provost, Faculty Human Resources, Curriculum and Assessment, Instructional Design, Trefry Library, Electronic Course Materials, and the Center for Teaching and Learning, as well as operational departments such as Advising, Registrar, Marketing, Enterprise Data Office, Workforce Learning Solutions, and Military and Corporate Outreach.
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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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Supervised, managed, or served as a project lead to accomplish performance and project goals; possesses knowledge of employee relations (e.g., performance or conduct based actions) and/or labor relations (e.g., grievance process or negotiations) practices.
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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. Work with Campus Grounds crew on special projects and tasks.
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Assist Members with but not limited to (benefits, PCP lookup, appointment setting, scheduling transportation, and documenting Grievance and/or appeals). The Member Care Professional may also facilitate the process for Health-Education related activities and other Health Plan functions and events.
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Act in compliance with applicable state and federal regulations (Release of Information, Grievance and Appeals procedures, etc.) Benefits Highlights Coverage: Health, vision and dental through Anthem Blue Cross Blue Shield, FSA, HSA that comes with an employer match, along with STD, LTD, life insurance, EAP, and more.
$50,000 - $75,000 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department via computer and virtual meetings. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care via phone/ computer work.
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Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Utilization Management Nurse:Performs prospective, first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
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Supporting the faculty counseling and faculty grievance and appeals processes related to mission area. Recruit, engage, and/or sustain a qualified faculty for the Department as determined by available resources and with advice and consent of the Dean and health system leaders.
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Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews. Demonstrate understanding necessary to assess, review and apply criteria (e.g., MCG guidelines, CMS criteria, medical policy, and health plan specific criteria.
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As needed, perform reviews on utilization review, appeals and grievance cases. Manage labor and non-labor expenses to budget or ? Deep knowledge of health plan clinical operations including but not limited to population health, value -based care, risk-based contracts/products and health plan clinical operations.
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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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grievance appeals and jobs
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