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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.
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Represent the State on all appeals of post-conviction relief cases handled in the circuit court when appealed to the Supreme Court and Court Appeals. File and serve appeals on behalf of the State in all cases in which relief is granted unless approval not to pursue an appeal is obtained from the Chief Deputy Attorney General.
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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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May also engage in grievance and appeals reviews. Become a part of our caring community and help us put health first. 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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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. After training, the permanent schedule is an Monday-Friday, starting as early as 7 am CST and ending as late as 7 pm CST.
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Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Knowledge of CPT-4, ICD-10, HCPCs, and provider billing practices.
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Assists Medicare members with the Part D grievance, coverage determination (including exceptions), and appeals process. We are an integrated, not-for-profit health system based in Salt Lake City, Utah, with clinics, a medical group, affiliate networks, hospitals, homecare, telehealth, health insurance plans, and other services, along with wholly owned subsidiaries including SelectHealth, Saltzer Health, and Intermountain Healthcare in Nevada.
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Serves on various committees such as faculty, curriculum, advisory, grievance, dispositions, exception requests, appeals, etc. Under the direction of the Provost & Vice President of Learner Experience, the AVP Academic Delivery role leads the logistical operations of Nightingale College (NC)to provide an orderly, efficient, and predictable academic environment for the learners, faculty, and staff of Nightingale College.
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