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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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Under general supervision of the Grievance and Appeals Manager performs a variety of complex, responsible and confidential duties requiring a thorough knowledge of organizational procedures and precedents perform routine clerical, administrative duties in support of the Grievance and Appeal Department.
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Assist members who have filed appeals or grievances to access care by assisting with prior authorizations, securing appointments, obtaining durable medical equipment, medications, transportation and other services as needed to resolve the grievance/appeal.
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In-depth knowledge of managed care medical management including UM/CM, Grievance and Appeals, inpatient and outpatient services, medical policy, clinical claims review, MassHealth and CMS requirements.
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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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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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The QM Appeals and Grievances Coordinator captures, investigates and responds to complaints regarding member grievances and appeals involving provisions of services and benefit coverage issues.
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Participates in ongoing communication to participant/decision maker about Participant Rights, Grievance and Appeals Process, and Care Planning. Experience with SOX compliance, testing and test plans, and knowledge of COSO and COBIT.Certified Internal Auditor (CIA), Certified Information Systems Auditor (CISA), Certified Fraud Examiner (CFE), Certified Public Accountant (CPA) and/or an advanced degree is a plus.
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The Grievance and Appeals Nurse Specialist participates in managing CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.
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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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Departments reporting to this position include: Appeals and Grievance, Claims, Enrollment and Reconciliation, Premium Billing, Member Service and Experience, and Member Innovation.
$300,000 - $350,000 a yearFull-timeExpandApply NowActive JobUpdated Yesterday - UpvoteDownvoteShare Job
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Monitors the work between cross-functional departments by coordinating support to Enrollment, Reconciliation, Premium Billing (ENR), Claims, Grievance and Appeals (GAD) departments.
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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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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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