- LA Care Health Plan (Los Angeles, CA)
- Appeals & Grievances Regulatory Audit Readiness Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los ... verified through reconciliation of end to end on all regulatory functions. Duties Audit readiness: Performs ...Required: A minimum of 5 years of experience in regulatory auditing ( Appeals & Grievances ,… more
- Commonwealth Care Alliance (Boston, MA)
- 011540 CCA- Appeals & Grievances **Position Summary:** Appeals and Grievances Program Advisor monitors and supports the operations and compliance of the ... Appeals and Grievances department through many NCQA...audit . + Participate in data quality checks for regulatory reporting submissions by verifying data in Guiding Care… more
- VNS Health (Manhattan, NY)
- …meet our high standards for operational and regulatory compliance in managing grievances and appeals on our behalf. * Data-Driven Decisions: Maintain the ... Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long...processes and timeframes. Maintains readiness for DOH or CMS audit at all times. + Ensures regulatory … more
- Beth Israel Lahey Health (Burlington, MA)
- …and appropriate departments. Utilize an audit tracking system (Cobius) to monitor audit processes, dollars at risk, and appeals . Provide support and training ... making a difference in people's lives.** Manages all functions of the ROI/ Audit and Research Department. Utilize technology to support ongoing efforts to protect… more
- CVS Health (Oklahoma City, OK)
- …every day. **Position Summary** Responsible for intake, investigation and resolution of appeals , complaints and grievances scenarios for all products, which may ... responses from multiple business units. Ensure timely, customer focused response to appeals , complaints and grievance. Identify trends and emerging issues and report… more
- Henry Ford Health System (Detroit, MI)
- …Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals . + Demonstrated experience at a professional ... GENERAL SUMMARY: Under the direction of the Compliance Audit Manager, the Principal Compliance Investigator will oversee compliance auditing and monitoring to assess… more
- Somatus (Mclean, VA)
- …Special Need Plans (SNPs). The Director, Quality will work closely with Sr. Manager, Audit Risk and the Regulatory and Accreditation Team to ensure compliance ... with audits, complaints/ grievances , and adherence to contractual obligations and Service Level...pre-delegation audits, annual client audits, development of grievance and appeals workflow processes, and other regulatory requirements.… more
- CHS (Clearwater, FL)
- …client trust. * Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS. Participates ... auto-adjudicated, in Examiner queues waiting to be adjudicated, and in either audit or needing approval status. * Developing and implementing strategies for greater… more
- LA Care Health Plan (Los Angeles, CA)
- …is the liaison in external and or (CMS) claim audits Organization Determination, Appeals & Grievances (ODAG) of delegates and subsequently monitors delegates ... Plans Auditor III is responsible for planning audits and audit work programs that address appropriate claims and financial...reviewed and approved by management prior to submission for Regulatory Affairs & Compliance and Legal review. Monitors the… more
- Molina Healthcare (Tampa, FL)
- …entities and Molina Healthcare. This includes claims, contact center, credentialing, appeals and grievances , care management, utilization management, pharmacy, ... oversees, and monitors delegated vendors' compliance with state and federal regulatory requirements. **Job Duties** **Strategic Direction and Collaboration:** + Set… more