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There are 3 Learning Program Manager positions available for this team:One of the positions will support Hollie McKitrick, working across all CXO supported lines of business (Commercial, Government, Member, Provider, Claims, Enrollment and Billing, and Grievance and Appeals)One of the positions will support Leila Allam, working across Commercial Member including National, Local Large Group, and Individual Small Group.
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Job Description :Manager II Grievance/Appeals – Claims Support Location: *CA Residential Requirement This position will work a hybrid model (remote and office). The Manager II Grievance/Appeals is responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to client/provider grievances/appeals and ensure compliance with regulatory requirements.
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One of the positions will support Stacy Serad, working across Commercial Provider, UM Intake, Claims, Enrollment and Billing, and Grievance and Appeals. Minimum Requirements: Requires BA/BS degree in organizational development, business, education, instructional design, or other learning discipline and a minimum of 8 years of experience, including a minimum of 7 years of project management experience; or any combination of education and experience, which would provide an equivalent background.
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Assists in creation of reports, attends, and presents at Plan committee meetings (Grievance, SIC, etc.) Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards.
$86,700 - $190,700Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Serves as a coach or mentor for other learning consultants and learning associates across Learning & Development when partnering on projects/initiatives. Job Description :Location: Within 50 miles of any Elevance Health Pulse Point locationShift: Monday – Friday; 1st shift hoursThe Learning Program Manager is an individual contributor on the CXO L&D Team and will operate in a highly fungible role responsible for direct engagement, support, leadership, and relationship management of supported lines of business.
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Position SummaryThis role will support the Grievance & Appeals and Delegated Ops businesses and provide subject matter expertise for Clinical Services FP&A consolidations. Proficiency with Microsoft Excel and PowerPoint is needed along with experience with Aetna Finance systems and processes.
$60,300 - $139,200Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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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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Provides guidance on risks that may impact the appeals and grievance operations. Manages appeals and grievance process in accordance with the organization's policies and procedures.
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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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The SCA Appeals Representative I position is an entry-level position in the NGS 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, (Part A & B) 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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Provider Services Grievance and Appeals. The Grievance and Appeals (G&A) Customer Service representative will oversee the Gainwell Grievance and Appeals team for our Ohio Department of Medicaid client.
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Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary. The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.
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Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
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Strong working knowledge of applicable laws and regulations, including current appeals guidelines established by the Centers for Medicare and Medicaid Services (CMS), and the ability to research Medicare and Medicaid regulations to ensure compliance and protect the company from sanctions, enforcement actions and penalties.
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Apply appropriate processes and procedures for medical claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates.
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