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The Appeals and Grievance Specialist is responsible for managing the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards.
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The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process.
$33.3 - $44.49 an hourFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
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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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Enters data and assists with compiling reports and analysis on the grievance and appeals process. Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
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What you will do: Coordinate the workflow and operations of two units within the grievance and appeals department, commercial and Government Programs. Why this job matters:Manage the daily work of administrative grievance and appeals staff to ensure adherence to quality standards, deadlines, and proper procedures.
$80,100 - $120,200ExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Provides oversight and supervision to the grievance and appeals staff to address complaints received from or on behalf of members served. This position oversees the hospital Grievance and Appeals process, ensuring compliance with mandated process and timelines associated with these reviews.
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Monitor Epic work queues on a routine basis to support hospitals and ancillary facilities in grievance and appeals cases and collaborate with hospitals and Central Office departments to resolve aging accounts.
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Must have reliable transportationCompany DescriptionBoutique law firm handling mostly landlord-tenant litigation including, but not limited to, evictions, eviction appeals, bankruptcy, premises liability, code compliance, fair housing, and business to business disputes.
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Supervise the functions of Grievance and Appeals (A&G) analysts and administrative support staff. Supporting Responsibilities:Provide backup for grievance and appeals staff as needed.
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Comprehensive knowledge of federal, state, and local laws, ordinances, codes, and regulatory standards applicable to municipal government. Extensive knowledge of the principles of personnel management, including employee/labor relations experience as well as experience in a union environment including negotiations, contract administration and grievance management.
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The Bureau of Human Resources, Department of Labor Relations seeks a Hearing Officer to be a liaison on behalf of Cook County management in serving as a mediator for union grievance hearings, resolution meetings, and other Labor/Management activities.
$93,662 - $116,643 a yearFull-timeExpandApply NowActive JobUpdated 8 days ago - UpvoteDownvoteShare Job
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You Have: 3+ years direct experience with federal regulatory examinations (FDIC, FRB, OCC, or CFPB) and bank partnership lending models. You will work with partners in legal, operations, compliance, finance, data analytics and engineering, product and other teams, to ensure that Block is compliant with applicable requirements and obligations while, to the extent possible, streamlining regulatory impact and facilitating innovation.
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Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department. Competent understanding of NCQA and federal regulatory requirements.
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What we're looking for Unrestricted RN license or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process, with emphasis on excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
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appeals regulatory and grievance jobs Company: Metropolitan Jewish Health System
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