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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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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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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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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. Job Description :Clinical Operations Associate Medical DirectorCarelon Medical Benefit ManagementInterventional Pain Benefit ReviewLocation: This position will work a hybrid model (remote and office.
Full-timeExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required. Review and evaluate appeal and grievance request 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.
ExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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May be called upon to testify on behalf of the Company during the Union grievance process, Accident Review Committee meetings, Safety appeals meetings, and other legal or administrative proceedings.
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Provide direct support to the Quality Review nursesProvide after hours and weekend coverage on a rotational basis to support 24/7 appeals work. Medical Management - Medicare Complaints, Grievance & Appeals experience.
$174,070 - $374,900Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology. 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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Preferred Skills, Capabilities, and Experiences:Board certification in Pain Management strongly preferred. Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJIn 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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Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
ExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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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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Familiar with grievance and appeals process. Experience in government payer claim adjudication (Medicare, Medicaid, VA, Tricare) and commercial payers (BCBS, Aetna, Cigna, UHC, etc.
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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider),grievance and appeals (member/provider) via target system. Handles incoming requests for appeals and preauthorization not handled by Clinical Claim Management.
$17 - $27.9Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Oengaging and retaining talented faculty to fulfill the needs of the Department and those of the SOM.omonitoring and responding to engagement surveys and exit reports; andocounseling, grievance, and appeals processes.
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Department(s): Grievance & Appeals Resolution Services (GARS)Reports to: Manager, Grievance & AppealsSalary: $24.52 - $31.04 Duration: up to 6 months Job Summary The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions.
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