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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. Job Description :Clinical Operations Associate Medical DirectorCarelon Medical Benefits ManagementRadiology Benefit Management/Utilization ReviewA proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois.
Full-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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May also engage in grievance and appeals reviews. 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 3 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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Description Clinical Operations Associate Medical Director Carelon Medical Benefits Management Radiology Benefit Management/Utilization Review A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. 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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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 7 days ago - UpvoteDownvoteShare Job
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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.
$24.52 - $31.04 an hourTemporaryExpandApply NowActive JobUpdated 10 days ago - UpvoteDownvoteShare Job
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Provides Referrals to Quality Management (QM), Disease Management, Social Services and Appeals and Grievance department (AGD). Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians.
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Meets performance measurement goals for Grievance and Appeals Resolution Services. Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
$25 - $31 an hourFull-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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The incumbent will collaborate with the other Medical Directors and clinical, nursing and non-clinical leadership staff across the organization in areas including Quality Management, Utilization and Care Management, Health Education/Disease Management, Long Term Care, Pharmacy, Behavioral Health Integration, Program for All Inclusive Care for the Elderly (PACE) as well as support departments including Compliance, Information Technology Services, Claims, Contracting and Provider Relations.
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Preferred QualificationsKnowledge 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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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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Job Summary The Manager, Health Plan Business Operations for Grievances and Appeals is responsible for managing health plan operations and regulatory compliance with emphasis on grievances and appeals, utilization management and claims processing.
$86,756 - $130,134Full-timeExpandUpdated 3 days ago - UpvoteDownvoteShare Job
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DutiesConducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.
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Identify medical management operational improvements, including those within the medical director area. Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists.
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