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You will have the responsibility of responds to adults in custody communications, grievances, grievance Appeals, and public complaints, requests, and questions. Working Conditions Work is performed in an office setting in a correctional facility and includes extended sitting time at a computer terminal, involvement in telephone conversations, research in manuals, writing various documents, climbing ladders, bending, stooping and stretching to reach/obtain/maintain AIC files.
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Review Level of Care for iCare members including follow-up consultation with Grievance and Appeals or Enrollment/Eligibility/Fiscal staff. Review Level of Care for iCare members including follow-up consultation with Grievance and Appeals or Enrollment/Eligibility/Fiscal staff.
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Makes medical necessity determinations for grievance and appeals appropriate for their specialty. Makes medical necessity determinations for grievance and appeals appropriate for their specialty.
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Ensure compliance with the grievance process including review of client terminations and appeals. The Salvation Army Mission: The Salvation Army, an international movement, is an evangelical part of the universal Christian church.
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May also engage in grievance and appeals reviews. Become a part of our caring community and help us put health first. 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.
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Serve as Hearing Officer for grievances and disciplinary appeals at the Step II level. -Professional experience with all steps of the grievance process, policy development, dispute resolution, as well as necessary familiarity with agency management and operations.
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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. 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.
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The clinical scenarios predominantly arise from inpatient or post-acute care environments. 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.
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Health Plan Core systems i.e. Claims, Membership, Grievance and Appeals. Health Plan Core systems i.e. Claims, Membership, Grievance and Appeals. BPM applications, i.e. PEGA. Primarily Manual testing experience this is NOT a automation testing role.
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The DMEPOS Clinical Operations Associate Medical Directo r is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers pertaining to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.
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Experience with national guidelines such as MCG or InterQualExperience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialistsExposure to Public Health, Population Health, analytics, and use of business metrics.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists.
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Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists. Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization. Advanced degree such as an MBA, MHA, or MPH. Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business.
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Conducts monthly quality assurance check of cases to ensure compliance to AlohaCare policies, state and federal laws, rules and regulations regarding Grievance and Appeals processing. Identifies trends and with Grievance and Appeals Manager in improving operational processes that impact on member satisfaction and complaint numbers.
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grievance appeals jobs
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