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Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member's appeal or grievance is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state or federal specific regulations that apply.
Full-timeExpandApply NowActive JobUpdated 14 days ago - UpvoteDownvoteShare Job
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The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
ExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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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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Is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
ExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member's appeal or grievance providing further appeal options as appropriate.
Full-timeExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing. This individual prepares cases for presentation, discussion, review and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed.
Full-timeExpandApply NowActive JobUpdated 20 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.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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Prepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Prepares and maintains case files and database for appeals and grievances in accordance with SHP, DHS, CMS, and DMHC requirements and NCQA accreditation standards.
Full-timeRemoteExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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Must be able to organize, plan and implement the functions of Member Appeals and Grievances, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws.
Full-timeExpandApply NowActive JobUpdated 17 days ago - UpvoteDownvoteShare Job
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Title: Grievance/Appeals Analyst I. Grievance/Appeals Analyst I. The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements.
RemoteExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
ExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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Investigate member and provider appeals and grievances and NCDOI, Congressional and/or Department of Justice complaints for all lines of business, excluding FEP, by reviewing applicable resources (i.e. CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, client management, and/or NCQA requirements.
Full-timeExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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Key Responsibilities/Duties – what you will be doing Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing. Key Responsibilities/Duties – what you will be doing Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
ExpandApply NowActive JobUpdated 3 days ago - UpvoteDownvoteShare Job
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Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews. Conducts audit reviews of Organization Determinations, Adverse Determinations and Notice of Medicare Non-Coverage documents (NOMNC) and Detailed Explanation of Non-Coverage (DENC) documents to assure accuracy and compliance with UM health plan, CMS, NCQA, URAC and Department of Insurance guidelines.
Full-timeExpandApply NowActive JobUpdated 29 days ago
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