- CDPHP (Albany, NY)
- …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- VNS Health (Manhattan, NY)
- OverviewResolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage ... appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting… more
- AscellaHealth (Berwyn, PA)
- What we are looking for Optime Care seeks a Prior Authorization and Appeals Specialist for our Berwyn, PA location. We are looking for someone who is passionate ... Appeals process. + Respond to Prior Authorization denials and submit appeals , collecting appropriate clinical support to substantiate the formal response. +… more
- University of Utah (Salt Lake City, UT)
- …Number** PRN41434B **Job Title** Outpatient/Provider Coder Level 3 **Working Title** Medical Appeals & Coding Specialist III **Job Grade** E **FLSA Code** ... attributes too. We are looking for an experienced **Medical Appeals & Coding Specialist ( MAC )...III , you will analyze and translate medical and clinical diagnoses, procedures, injuries, or illnesses into designated numerical… more
- Robert Half Accountemps (Los Angeles, CA)
- …Medical IPA Company in Mid-Wilshire is seeking a dedicated and detail-oriented Grievance and Appeals Specialist to join our team. The ideal candidate will play a ... members receive excellent service and fair resolution of grievances and appeals in compliance with regulatory guidelines. This position requires strong analytical… more
- Molina Healthcare (Austin, TX)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of previously denied cases in which… more
- Elevance Health (San Antonio, TX)
- …grievance committees/hearings. + Summarizes and presents essential information for the clinical specialist or medical director and legal counsel. **Minimum ... easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty...or outside consultant. + Triages clinical and non- clinical inquiries, grievances and appeals , prepares case… more
- Independent Health (Buffalo, NY)
- …coding guidelines and financial policies/contracts. + Responsible for all reconsideration clinical appeals to include review of records, consultation with ... and a culture that fosters growth, innovation and collaboration. **Overview** The Clinical & Coding Specialist -Senior will be responsible for reviewing coding… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …through our Healthsource blog: https://healthsource.premera.com/ . The **Medical Policy (MP) Clinical Specialist ** is a critical role in Premera, responsible ... with utilization management (UM) to promote usability. The MP Clinical Specialist monitors and updates policies associated...and other sources. + Liaise with Utilization Management and Clinical Appeals Departments to regularly review data… more