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Prepare responses to moderately complex questions on contract provisions, documents and cases scheduled for arbitration, grievance appeals from labor organizations, and dispute resolutions.
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The Grievance and Appeals Coordinator will also present cases to the Appeals Committee. Ability to function and excel in a remote environment handling time critical appeals and grievance cases.
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Minimum of two (2) years in managed care setting, Care Management, Utilization Management and/or Grievance and Appeals experience. The Clinical Utilization Registered Nurse works directly with the Clinical Utilization Director in supporting clinical decisions for hospital and skilled nursing admissions, decisions on Personal Care Aide services for high hour cases, and decisions for high dollar medical equipment.
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Experience of handling ER cases including disciplinary and grievance, appeals, absence management and redundancy. Providing operational support and advice on employee relations matters; such as disciplinary, grievance, appeals.
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Supports the SMI Grievance and Appeals team with complex clinical cases related to SMI rights and related care. Works closely with the Office of General Counsel Services on the clinical issues that arise in the grievance and appeals process and participates in Administrative Hearings.
ExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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The Appeals and Grievance Coordinator will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare.
ExpandApply NowActive JobUpdated 11 days ago - UpvoteDownvoteShare Job
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Testify for AHCCCS in the Appeals and Grievances process as it relates to clinical issues. Participate in AHCCCS Coding and Billing Review Team. Provides guidance on AHCCCS Medical Policy Manual (AMPM) and program implementation.
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Assist in the development of internal physician advisors and provide support in developing solutions for complex cases, in the authorization and denial of services, and in the grievance and appeals process.
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Conducts monthly quality assurance check of cases to ensure compliance to AlohaCare policies, state and federal laws, rules and regulations regarding Grievance and Appeals processing.
$19.75 - $26 an hourFull-timeExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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Represents PHC in the Grievance & Appeals Resolution process. Independently determines best resolution on assigned cases, incorporating clinical guidancefrom PHC Medical Directors and Grievance & Appeal Nurse Specialists.
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Provide comprehensive representation of employees and/or unions in employment matters, including but not limited to representation in administrative discipline cases, dismissals, grievance hearings, unfair labor practice charges, State Personnel Board appeals, arbitrations/mediations, and trials as required.
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Handling a HR case work portfolio, including disciplinaries and grievance investigations, hearings and appeals. Working with managers to fully manage case work proactively at both informal and stages, referring complex cases and significant risks to the Employee Relations and Policy Manager and/or relevant HR Business Partner.
ExpandApply NowActive JobUpdated 12 days ago - UpvoteDownvoteShare Job
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Health Plan Core systems i.e. Claims, Membership, Grievance and Appeals. Experience creating test cases, test features manually, creating test strategy documents. Health Plan Core systems i.e. Claims, Membership, Grievance and Appeals.
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Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business-based turnaround time.
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Assist consumers with the filing, pursuit, and resolution of complaints and appeals through existing processes, including internal reviews conducted by health benefits plans, grievance and appeals processes for the HealthCare Alliance, fair hearings available to Medicaid consumers, external reviews before independent review organizations, and any other administrative appeals available under District or federal law.
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