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Experience in appeals and grievance involving Compliance. Experience in appeals and grievance involving Compliance. If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS.
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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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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. 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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Provides guidance on risks that may impact the appeals and grievance operations. Manages appeals and grievance process in accordance with the organization's policies and procedures.
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The Director is responsible for all aspects of the member appeals and grievance processes for all lines of business across the enterprise, including Commercial, Senior Products, Public Plans, joint ventures, and other state sponsored products.
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The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
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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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The Grievance and Appeals Coordinator will also present cases to the Appeals Committee. The Appeals and Grievance Coordinator will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare.
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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.
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Demonstrate a solid understanding of the appeals and grievance processes, including all regulatory and reporting requirements. Direct and manage appeals and grievance staff in order to adhere to accurate processing and resolution of appeals and grievances.
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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 Judge Group is a Program Assistant for a great healthcare client in Orange, CA. Job Description:Under general supervision, the Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services (GARS) department.
$23 - $29 an hourExpandUpdated 3 months ago - UpvoteDownvoteShare Job
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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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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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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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