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The Program Manager is a key member of the Medicare Advantage Claims, Configuration and Appeals and Grievance Operations team. Assists in planning, developing, implementing, and managing the Medicare Advantage Claims, Appeals and Grievance program requirements, operational initiatives and policies.
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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. May also engage in grievance and appeals reviews.
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Experience with national guidelines such as MCG or InterQual + Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization + Advanced degree such as an MBA, MHA, or MPH + Exposure to Public Health principles, Population Health, analytics, and use of business metrics.
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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider),grievance and appeals (member/provider) via target system. Handles incoming requests for appeals and preauthorization not handled by Clinical Claim Management.
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Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation.
$45,850 - $55,500 a yearFull-timeExpandApply NowActive JobUpdated 6 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.
ExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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Managing case work end to end covering settlements, PIPs, absence management and all aspects of grievance and disciplinaries (investigations, hearings, mediations, appeals, terminations) in line with legal requirements and company policy.
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Our offerings, powered by the iTwin Platform for infrastructure digital twins, include MicroStation and Bentley Open applications for modeling and simulation, Seequents software for geoprofessionals, and Bentley Infrastructure Cloud encompassing ProjectWise for project delivery, SYNCHRO for construction management, and AssetWise for asset operations.
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Become a part of our caring community and help us put health first. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.
ExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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Degree in human resources /business or related field with six to eight years of experience in the field of HR (compliance, corporate employment law, or HR operations). Our industry-leading software solutions are used by professionals, and organizations of every size, for the design, construction, and operations of roads and bridges, rail and transit, water and wastewater, public works and utilities, buildings and campuses, mining, and industrial facilities.
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Medical Director - Southeast Region - Work from Home at Humana in Boise, Idaho, United States Job Description Become a part of our caring community and help us put health first The Medical Director relies on medical background and reviews health claims.
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Seek to resolve differences in accordance with the scriptural patterns summarized in the Staff Manual policy on Fair Treatment as well as the Grievance and Appeals Procedure. Seek to resolve differences in accordance with the scriptural patterns summarized in the Staff Manual policy on Fair Treatment as well as the Grievance and Appeals Procedure.
ExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Grievance and Appeals experience. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Conducts investigations and reviews of member and provider grievances and appeals.
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Liaison to Services team coordinating efficient and accurate member ad provider servicing as well as Grievance and Appeals processing according to CMS requirements and regulations. Liaison to Services team coordinating efficient and accurate member ad provider servicing as well as Grievance and Appeals processing according to CMS requirements and regulations.
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The clinical scenarios predominantly arise from inpatient or post-acute care environments. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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