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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. Medicare Appeals Specialist. Filing complaints with Medicare and Medicaid agencies when claims are denied in error.
ExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Review and evaluate appeals and grievance requests 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.
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Manages the relationship with both new and established vendors, including but not limited to customer service, claims processing, enrollment, medical management, credentialing and grievance and appeals.
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Maintains knowledge of grievance/appeal reporting requirements for the Office of the Center of Medicare/Medicaid Services, DHS, and Metastar. This position interfaces with the Department of Health Services (DHS), the Division of Hearings and Appeals (DHA), Ombudsman Program, the.
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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.
ExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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Job SummaryThe Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines.
Full-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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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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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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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.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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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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Exposure to Public Health, Population Health, analytics, and use of business metrics. 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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Coordinate the workflow and operations of two units within the grievance and appeals department, commercial and Government Programs. Manage the daily work of administrative grievance and appeals staff to ensure adherence to quality standards, deadlines, and proper procedures.
Full-timeExpandApply NowActive JobUpdated 15 days ago - UpvoteDownvoteShare Job
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Other duties include, but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc.
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The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type.
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