- Elevance Health (Indianapolis, IN)
- **Title: Grievance / Appeals Representative I** **Location:** This position will work a hybrid model (remote and office). Ideal candidates will live within 50 ... miles of one of our PulsePoint locations. The ** Grievance / Appeals Representative I** is responsible for reviewing, analyzing and processing claims in… more
- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** Appeals and Grievances Representative supports the Operations Department and the Appeals and Grievances team in a ... **What You'll Be Doing:** - Processing of Grievances & Appeals . - Responsible for the progress of grievance... Appeals . - Responsible for the progress of grievance and appeal intervention and resolution. - Assure verbal… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, September 9, 2024 Centers Plan for Healthy Living's goal ... the guidance and plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial… more
- MTA (New York, NY)
- …and participate in monthly conferences with union representatives to discuss contract grievance and employee discipline appeals ; perform analytical review of ... Senior Labor Relations Representative Job ID: 6749 Business Unit: MTA Headquarters...sanctioned by the National Mediation Board for all contract grievance and employee discipline cases. + Provide leadership and… more
- Commonwealth Care Alliance (Boston, MA)
- …members and all those involved in CCA members' care. The Member Service Representative (MSR) is responsible to provide a best-in-class service experience to all ... including provider listings in their areas. + Complete comprehensive appeal and grievance intakes. + Collaborate with the member to accurately document their appeal… more
- CVS Health (Oklahoma City, OK)
- …Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. + Educates ... customer-focused professionals supported by exemplary technologies and processes. Customer Service Representative is the face of Aetna and impacts members' service… more
- Prime Care Coordination (Webster, NY)
- …at least one of the following areas: call center operations, MLTC, grievance and appeals , and/or authorizations. Physical Requirements/Working Conditions: + Must ... Summary: A Member Services Representative is responsible for providing iCircle members with...service in a call center environment. A Member Services Representative provide accurate and efficient services to ensure that… more
- Highmark Health (Dover, DE)
- …This position is also responsible for assisting members in navigating the grievance and appeals process and representing member interests internally and ... Service **Preferred** + Familiarity as a Member Advocate or with complaint and grievance processes + Familiarity with Delaware Medicaid and the Medicaid LTSS benefit… more
- CVS Health (Boston, MA)
- …+ Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system . + ... Educates & assists providers on our self-service options. Assists providers with credentialing and re-credentialing and contracting questions and issues. + Assists in compiling claim data for customer audits. Determines medical necessity, applicable coverage… more
- Highmark Health (Providence, RI)
- …and member requests, received from Medical Management & Policy (MM&P) and Member Grievance Departments. * Responsible for management of Peer to Peer telephone line. ... timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory… more