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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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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.
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Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members. The MSR performs a variety of complex functions and is also responsible for maintaining accurate and complete inquiry/grievance records in the electronic database.
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Review decision letters regarding appeals and grievance for accuracy prior to delivery. Review decision letters regarding appeals and grievance for accuracy prior to delivery. Provide technical interpretations and guidance on Human Resource Management matters such as employee relations, labor relations, payroll and benefits, classification, staffing, and recruitment.
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Commercial Grievance and Appeals knowledge is highly preferred. Commercial Grievance and Appeals knowledge is highly preferred. Experience and knowledge with PEGA NextGen is highly preferred.
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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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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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The Claims Supervisor is responsible for the day-to-day management of the Senior Analyst claims team, who handle a variety of tasks including, but not limited to, Customer emails, Correspondences, Grievance and Appeals, HRA, Balance Bills and Transplants, enabling the team to deliver exceptional service to our customers.
ExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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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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Recommend to Program/Clinical Director action on student grievance and appeals. Recommend to Program/Clinical Director action on student grievance and appeals. CSN employs only U.S. citizens and aliens authorized to work in the U.S. CSN does not sponsor aliens applying for faculty, professional staff, or management positions (H-1B Visas) in the absence of exceptional circumstances as defined by the USCIS.
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Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology. The Clinical Operations Associate Medical Director responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.
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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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Under general supervision of the Grievance and Appeals Manager performs a variety of complex, responsible and confidential duties requiring a thorough knowledge of organizational procedures and precedents perform routine clerical, administrative duties in support of the Grievance and Appeal Department.
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We are seeking a talented Grievance & Appeals Specialist who will be responsible for responding to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations.
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Description Clinical Operations Associate Medical Director Carelon Medical Benefit Management Interventional Pain Benefit Review Location : This position will work a hybrid model (remote and office). We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
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