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We are seeking a talented Grievance & Appeals Specialist who will be responsible for responding to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations.
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Minimum Requirements:Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.
Full-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD). Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
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Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.
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Will be responsible for reviewing, analyzing, and processing complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department and the completion of written communication documents to convey the determination.
ExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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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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Responsible for initiating the initial research on the appeal/grievance from the numerous systems to ensure all data is captured for entry into the appeals and grievances system. Responsible for the initial assessment, review, and determination of the validity of an appeal and/or grievance type for all cases coming into the department.
Full-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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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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Represents PHC in the Grievance & Appeals Resolution process. Independently determines best resolution on assigned cases, incorporating clinical guidance from PHC Medical Directors and Grievance & Appeal Nurse Specialists.
Full-timeExpandApply NowActive JobUpdated 6 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.
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75 including internal DOT disciplinary proceedings, OATH trials, grievance proceedings and arbitrations, Civil Service Commission disciplinary appeals and related civil litigation; assist Investigative Staff in conducting disciplinary surveillances; review and evaluate evidence; conduct legal research, prepare legal memoranda and briefs; investigate and prosecute fitness complaints pursuant to Civil Service Law.
Full-timeExpandApply NowActive JobUpdated 9 days ago - UpvoteDownvoteShare Job
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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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Focus on quality review of grievance and appeals cases for all LOB to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to Client's membership.
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The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process that meets state, federal, accreditation and other regulatory requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations about appropriateness of care, and expedite cases within established criteria and contract requirements.
Full-timeExpandApply NowActive JobUpdated 6 days ago - UpvoteDownvoteShare Job
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Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD) In this role you will determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits.
ExpandApply NowActive JobUpdated 7 days ago
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