information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management... in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including...
related to follow-up, denials, and appeals. Essential Duties and Responsibilities Examines denied and underpaid claims... experience in hospital and/or physician clinical areas. Preferred: Prior experience in Medicare or Medi-Cal (Medicaid...
areas. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization... a balance between individual clinical needs with the efficient and cost-effective utilization of resources while promoting...
clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical... Management (DM) and Appeals and Grievance department (AGD) Recognize the clients right to self-determination as it relates...
departments to ensure patient-centered care while managing costs effectively and improving quality of care. Senior Clinical.... Provide timely coverage determinations for drug prior authorizations (PA), exception requests, and appeals utilizing posted...
(i.e., QNXT) and the related surround systems, applications, and database (e.g., Clinical CareAdvance (CCA), Process Communication... quality assurance (especially related to claims, health services/population health as well as appeals and grievances systems...
Hub services, Copay Support etc. Ensure providers understand payer prior authorization requirements, appeals process..., and clinical criteria as it relates to Rezdiffra. Work effectively with both internal and external stakeholders to achieve target...
care plan to professional staff. Adheres to Home Health Agency administrative and clinical policies and procedures... under Civil Service Rule 110.4. Such appeals must be submitted in writing to the Department of Human Resources, 1 S Van Ness...
populations Supervising clinical and administrative professionals Improving clinical quality Engaging patients and improving... of this announcement may be appealed under Civil Service Rule 110.4. Such appeals must be submitted in writing to the Department of Human...
Clinical Documentation Specialist- (CCDS) or CIRCC-AAPC or Radiation Oncology Certified Coder (ROCC): Preferred Essential...-PCS coding guidelines for inpatient, outpatient, and/or clinic visit encounters that correlates to clinical documentation...
national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer... Prior Authorization (PA) Technician plays a key role in assisting the clinical review pharmacist with daily tasks...
reimbursement through coordination of patient care, daily clinical reviews, quality documentation, appeals, and reporting... care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic...
management (UM) and care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating... with members and those involved with members' care including clinical nurses and treating physicians. Responsibilities...
reimbursement through coordination of patient care, daily clinical reviews, quality documentation, appeals, and reporting... care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic...
and clinical best practice to concurrently screen admission review and review with payors in collaboration with Case Management... as the first line responder to payor’s clinical questions and for approval for admission, per established process. Manages...
Job Description: Your Role The Case Management team performs case management (CM) activities demonstrating clinical... judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses...
related to departmental services. You will build a high-performing team of Clinical Supervisors, Nurses Care Managers... eligible members. Provide direct oversight and guidance to the Clinical Supervisors and other staff, thereby creating a high...
. This position supports the clinical vision for the health plan(s) for all lines of business (Medicaid, Medicare, and Commercial...) and implements programs to support this vision. May serve multiple health plans managed by the Clinical Center of Excellence...
and preferences Provide Referrals to Quality Management (QM), Disease Management (DM), Complex Care Management (CCM), and Appeals..., evaluate, and interpret clinical information Pay Range: The pay range for this role...
pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical... plan. - Partners as needed with the appeals and grievances functions of the department. Qualifications...