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Medicare Advantage Appeals And Grievance Nurse Jobs

Member Advocate, Medicare Advantage
By CommuniCare Health Services At Akron, OH, United States
Strong time management skills required. Must be able to prioritize and adhere to competing deadlines.
2+ years healthcare experience or educational equivalent
Expert/Highly Skilled with computer skills: Windows-based applications and Microsoft applications
Advanced organizational and communication skills
Four-year advanced degree or equivalent work experience in healthcare payors, social services field, advocacy, customer relations, or other related industry
Skill in establishing priorities with independent coordination of day-to-day duties
Grievance And Appeals Coordinator - Remote | Wfh
By Get It Recruit - Healthcare At Sacramento, CA, United States

Are you a skilled communicator and problem solver with a knack for clear, concise writing? We're seeking a dedicated Member Support Specialist to join our team. As a crucial link between our members ...

Medicare Advantage Internal Audit Program Manager
By AllWays Health Partners At ,
Interact with LRAC and IAS management throughout the engagement, discussing work performed, status, findings and recommendations, client communications, and audit reports
Two to five years previous experience serving as manager/auditor for a Medicare Advantage/Part D plans
Bachelor’s Degree in Accounting or Business Administration from an accredited institution or the equivalent combination of training and experience.
Experience participating in audits conducted by the Centers for Medicare and Medicaid Services (CMS)
Healthcare/health insurance experience, CPA/CIA, also strongly preferred.
Information system audit experience is a plus.
Grievance & Appeals Quality Assurance Specialist
By SnugZ USA At New York, NY, United States
3 years quality management experience
Use problem solving skills and business knowledge to make recommendations for process remediation or improvement.
Update current workflows and draft future workflows, incorporating regulatory requirements, quality, and efficiency within design.
Auditing, researching, analyzing and evaluating grievance and appeals data to assess compliancy between process and the corresponding CMS and DOH regulations.
Coordinate, facilitate and document audit walkthroughs.
Develop training and refresher training.
Appeals & Grievance - Rn
By Yamhill Community Care At , Mcminnville
Knowledge of Managed Care / Medicaid requirements.
Maintains confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.
Any combination of education and experience that would qualify candidate for the position.
Health care benefit and regulatory knowledge.
Knowledge of Oregon Medicaid grievance system requirements.
Ensures resolutions are compliant and meets turnaround times requirements dictated by policies and procedures.
Marketing Manager (Alliances, Medicare Advantage)
By Delta Dental Ins. At , Remote
Develops metrics and reports for management and executive management use.
A minimum of 8 years of related experience preferred
Experience developing and executing marketing strategies and programs.
Experience leading cross-functional teams to achieve program objectives.
Strong analytical and problem solving skills.
Strong composition, editing, and proofreading skills.
Head Of Customer Operations, Medicare Advantage
By Stealth Ventures at Redesign Health At , New York $170,000 - $200,000 a year
You have expertise in the Medicare Advantage plan product design space, including management of Supplemental/SDOH benefits.
You have 10+ years of experience and progressive leadership responsibilities in Medicare Advantage product, strategy, and implementation roles.
You have 2+ years of early-stage startup experience.
You have experience leading an implementation team and new client onboarding and development of client KPIs/performance scorecard.
You have experience with go-to-market efforts and a proven record of developing new Medicare Advantage client partnerships.
You have strong analytical and problem-solving skills.
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
Senior Operating Executive - Medicare Advantage Expert
By Chicago Pacific Founders At United States

Based in Chicago and San Francisco, Chicago Pacific Founders ("CPF") is a leading strategic private equity firm focused on building and scaling companies within the healthcare services sector. This ...

Senior Operations Executive - Managed Care/ Medicare Advantage Expert
By Chicago Pacific Founders At United States

Based in Chicago and San Francisco, Chicago Pacific Founders ("CPF") is a leading strategic private equity firm focused on building and scaling companies within the healthcare services sector. This ...

Grievance & Appeals Specialist- Remote
By EmblemHealth At New York, NY, United States
Relevant Work Experience, Knowledge, Skills, And Abilities
Additional years of experience/training may be considered in lieu of educational requirements. (R)
Excellent organization and time management skills. (R)
Experience in a managed care/compliance environment. (P)
Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
3+ years of related professional work experience. (R)
Grievance/Appeals Analyst I (Us)
By Elevance Health At California, United States
Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
12898 Towne Center Drive, Cerritos, CA
3080 Bristol Street, Costa Mesa, CA
11030 White Rock Road, Rancho Cordova, CA
1121 L St., Suite 500, Sacramento, CA
2121 N. California Boulevard, Walnut Creek, CA
(Internal Employees Only)Lead Processor For Medicare Advantage, Medical Claims And De/Xc - Remote
By Moda Health At United States
Analytical, problem solving, retention of new knowledge, organizational skills.
1-2 years Moda Health claims processing experience preferred
Knowledge of medical terminology, HCPC codes, CPT codes and ICD-9/ICD-10 codes.
Demonstrated knowledge and understanding of plans processed by unit including complex claims and claims from various provider panels.
Effective written and verbal communication skills.
Performs manual calculation/override of benefit to enter correct information on claims the system cannot process.
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.
Quality Assurance Specialist, Appeals & Grievance
By Alignment Health At California, United States
Produces departmental quality performance reports for management review.
2+ years of managed healthcare experience.
Knowledge of Medicare Managed Care Plans required.
Possess the knowledge of Appeals and Grievance procedures and the Centers for Medicare (CMS) regulatory compliance guidelines.
Analyzes and validates accuracy of Appeals and Grievance data according to plan business and CMS regulatory technical reporting requirements.
2+ years healthcare appeals & grievances experience, related QA experience, or training/supervisory role.
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.