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Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.
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May also engage in grievance and appeals reviews. 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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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age.
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Serves on Quality Improvement & Health Equity Committee, Peer Review and Credentialing Committee, Grievance and Appeals Committee, Clinical Operations Committee and Physician Advisory Committees; serves on other committees as required.
ExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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In-depth knowledge of all aspects of managed care medical management, including UM/CM, Grievance and Appeals, medical policy, clinical claims review (professional and facility), and delegated vendor oversight.
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The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it.
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Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. Become a part of our caring community and help us put health first.
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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.
ExpandApply NowActive JobUpdated 9 days ago - UpvoteDownvoteShare Job
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Respond to escalated provider claim inquiries received by Provider Services, Grievance and Appeals and other Departments as needed. Minimum of five years in a managed care claims processing environment processing all claim types (e.g., inpatient, outpatient, professional, SNF, DME, Home Health, COB) required.
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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. Medicare Appeals Specialist. 3 to 5+ years of recent experience writing insurance appeals and pursuing Medicare for collection on behalf of hospitals (facility charges.
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Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists. Advanced degree such as an MBA, MHA, MPH. Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized.
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Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. Experience with national guidelines such as MCG.
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Required Qualifications: Associate's Degree Or equivalent combination of education and experience 3 years Familiarity with managed care contracting, provider operations and/or payer operations.
$25.72Full-timeRemoteExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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Under general supervision, the Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services (GARS) department. Monitors for inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), the Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS.
ExpandApply NowActive JobUpdated 13 days ago
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