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Maintains and ensures integrity of case file, documentation accuracy, and data collection systems, and prepares data reports and analysis of grievance and appeals for program management and committees, as needed.
$61,463.13 - $73,755.75 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a members 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.
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You will oversee the accurate, compliant, efficient, and timely configuration of claim benefits, regulatory and business rules, provider contracts, and appeals and grievance processing capabilities.
$67,400 - $133,400 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
$24.52 - $31.4 an hourExpandApply NowActive JobUpdated Yesterday - UpvoteDownvoteShare Job
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Department(s): Grievance & Appeals Resolution Services (GARS)Reports to: Manager, Grievance & AppealsSalary: $24.52 - $31.04 Duration: up to 6 months Job Summary The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions.
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Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for Oversight of processes related to resolution of grievance scenarios for all Medicare products, which may contain multiple issues and may require coordination of responses from multiple business units.
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The Appeals & Grievances Coordinator is responsible for the processing, tracking and follow up of all grievances, medical necessity and administrative denials and appeals. Must possess the ability to work cooperatively with health plan Appeal Divisions, such as CMS, AHCA and other federal and state regulatory agencies.
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Research and resolve grievance and appeals for the commercial line of business, utilizing a higher level of adjudicator expertise, clinical interpretation and decision making. Identify, investigate, and resolve billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through demand for refund of overpayments and education to providers.
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Collaborate with the Medical Directors to rank and respond to appeals, grievances, and Quality Issues (QIs), ensuring compliance with clinical appeal and grievance accreditation and regulatory standards.
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Minimum of four years of administrative support experience in a health care organization required Knowledge of DOH and CMS Grievance and Appeals regulatory requirements and procedures for ensuring compliance preferred Proficient PC skills, including MS Excel, Word, and Access required Knowledge of Facets system preferred.
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Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
$17 - $29.88 an hourFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Must have a thorough understanding and working knowledge of managed care, health insurance plans, regulatory, and other policies and procedures, including grievance and appeals practices.
$51,098 - $69,133 a yearFull-timeExpandApply NowActive JobUpdated Yesterday - UpvoteDownvoteShare Job
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Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals.
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Advanced knowledge and understanding of the specialty dental and vision businesses; Operations (claims, enrollment, grievance & appeals, etc.) Minimum Requirements:Requires a BA/BS and minimum of 6 years health care, regulatory, ethics, compliance or privacy experience; or any combination of education and experience, which would provide an equivalent background.
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Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary. The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.
$51,261 - $74,328 a yearFull-timeExpandApply NowActive JobUpdated Today
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