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Appeals And Grievances Quality Nurse Jobs

Appeals And Grievances Analyst
By Provisions Group At Nashville, TN, United States
• Review and interpret product and benefit designs according to State and Federal regulatory requirements
Education: Associates Degree or equivalent experience in health care, conflict resolution or related field.
• Health care benefit and regulatory knowledge preferred
• 3-5 years health care or insurance experience
• Knowledge of insurance products, policies and procedures preferred.
• Requires excellent interpersonal skills in order to communicate and work with multiple constituents.
Lead Analyst, Appeals & Grievances
By Molina Healthcare At United States
5 years of analytical skills and experience (query data, excel, and SharePoint)
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Guides staff by providing technical knowledge and functions as a subject matter expert to staff.
Experience with process improvement initiatives
Serves as a lead for incoming analysts by providing support.
Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
Appeals And Grievances Coordinator
By Clear Spring Health At Miramar, FL, United States

Candidates should have working knowledge of Medicare and member services or work in a health plan or health plan supprting vendor.

Appeals Nurse Consultant Jobs
By CVS Health At , Hartford $58,760 - $125,840 a year

Must have active and unrestricted RN licensure in state of residence

California RN license preferred (not required)

Rn Appeals Nurse (Hybrid)
By VillageCare At New York, NY, United States

Appeals Nurse (Hybrid) VillageCareMAX 112 Charles Street, New York, NY 10014 VillageCare is looking for a self-motivated and passionate RN for our Appeals Nurse position. While supporting the ...

Nurse Appeals (Contract) Jobs
By Elevance Health At , Los Angeles
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
100% Remote - Appeals & Grievances Non-Clinical Specialist - Medicare And Medicaid Knowledge Highly Preferred
By Healthfirst At Utah, United States
Experience working in care management systems, such as CCMS, TruCare or Hyland
Prior experience in a Managed Care or Healthcare environment
Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes and exceptional organizational skills.
Manage all duties within regulatory timeframes
Bachelor’s degree from an accredited institution or relevant work experience
Prior knowledge of Medicare and Medicaid health plans
Appeals & Grievances Analyst Jobs
By Point32Health At Massachusetts, United States
Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements
Health care benefit and regulatory knowledge preferred
Must be able to work under normal office conditions and in a remote capacity from home as required.
Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
Associates Degree or equivalent experience in health care, conflict resolution or related field
3-5 years health care or insurance experience
Registered Nurse (Rn) - Appeals & Grievances
By CareOregon At , Portland, 97204, Or $87,140 - $105,435 a year
Knowledge of utilization management practice principles and industry standard criteria
Knowledge, skills and abilities required
Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards
Knowledge of Oregon Health Plan benefit package including rules and regulations that pertain to health plan operations
Knowledge of Medicare A and B benefits and regulations that relate to Medicare Advantage plans
Physical Skills and Abilities Required
Nurse Appeals Jobs
By Elevance Health At Florida, United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Nurse Appeals Jobs
By Elevance Health At United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Appeals And Grievances Lead
By Gold Kidney Health Plan At United States
· Exceptional time management skills.
· Promote a provider-friendly, customer service-oriented philosophy within the Fresenius Health Partners Utilization Management department.
· Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications.
· 2 – 4 years’ related experience required
· Medicare Advantage Appeals and Grievance experience required.
· Excellent analytical and leadership skills.
Appeals Nurse Jobs
By Netsmart At United States
At least 3 years of case management, concurrent review or utilization management experience
Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
At least 5 years of clinical experience in acute care setting
Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.
Bachelor of Science degree in Nursing
Proficiency in medical record review
Appeals Nurse Jobs
By Mindlance At Ohio, United States
Experience with Utilization Review/Management--2 yrs
Utilization review nurse, appeal review nurse and direct patient care experience.
Share resume at : [email protected]
Behavior and accountability and ability to pivot when new priorities come up
Describe the performance expectations/metrics for this individual and their team:
What previous job titles or background work will in this role?
Nurse Appeals Jobs
By Elevance Health At Ashburn, VA, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Columbus, OH, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Richmond, VA, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Tampa, FL, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Member Appeals & Grievances Intake Administrator
By Fallon Health At Worcester, MA, United States
Assigning case files to the department staff for case management.
Responsible for additional clerical/administrative responsibilities at the discretion of the Director or Manager.
Print, mail, and triage letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA.
Managing incoming faxes and member specific data, routing to the appropriate staff member.
Producing, maintaining, and distributing reports/calendars utilized by the team to assist in workload planning.
Processes department incoming/outgoing mail per established workflows in a timely and accurate manner.
Nurse Appeals Jobs
By Elevance Health At Palo Alto, CA, United States
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.