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Adjudicate medically related grievances and appeals that flow through the Member grievance and appeals process. Chairperson/ Co-Chair of the HEDIS Improvement Committee, Quality Management Committee, Quality Improvement Committee, Credentialing Committee, Grievance Trend Committee k.
$240,676.8 a yearExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Collaborate with internal departments as necessary (Customer Service Center, Provider Network, Claims, Utilization Management, Pharmacy) to ensure the timely resolution of all appeals and grievances.
ExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. 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.
Part-timeExpandApply NowActive JobUpdated 6 days ago - UpvoteDownvoteShare Job
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The Director is responsible for leading the Appeals and Grievance Department management team and provides oversight for the day-to-day act ivies of the complex operations of the Appeals and Grievance Department.
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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. 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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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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In-depth knowledge of managed care medical management including UM/CM, Grievance and Appeals, inpatient and outpatient services, medical policy, clinical claims review, MassHealth and CMS requirements.
Full-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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May also engage in grievance and appeals reviews. Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
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The Clinical Operations Associate Medical Director responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.
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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.
ExpandApply NowActive JobUpdated 6 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.
Full-timeExpandApply NowActive JobUpdated 14 days ago - UpvoteDownvoteShare Job
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Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required.
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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 6 days ago - UpvoteDownvoteShare Job
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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. 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.
ExpandApply NowActive JobUpdated 15 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.
ExpandApply NowActive JobUpdated 15 days ago
grievance appeals utilization management jobs
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