- Humana (Providence, RI)
- **Become a part of our caring community and help us put health first** The Director , Grievances & Appeals manages the client medical denials experience ... in a timely manner to provide resolutions for Humana membership. The Director , Grievances & Appeals requires an in-depth understanding of how organization… more
- Humana (Providence, RI)
- …of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The Corporate Medical ... Director works on problems of diverse scope and complexity...complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness… more
- Highmark Health (Providence, RI)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with… more