grievance and appeals specialist

MEDIKO Inc

<div><p><b>MEDIKO</b><b>: </b>Mission driven &amp; committed to delivering high-quality medical care to the communities we serve.
</p><p>Our dedicated Healthcare Professionals find meaning, support and new opportunities to learn and grow their skills every day. It&rsquo;s what sets us apart from other healthcare industries and drives our success in the correctional healthcare space.
</p><p>Whether you are just graduating from nursing school or bringing years of experience to your new position at<b> </b><b>MEDI</b><b>KO</b><b>, </b>you will benefit from our competitive compensation, commitment to safety and exposure to the diverse healthcare needs of the clients we serve.</p><p>
If you&rsquo;re ready to take on a role that will enrich your career and make a real impact to your community, we encourage you to APPLY TODAY to get the conversation started!
</p><p>The Registered Nurse - Grievance and Appeals is responsible for the review, investigation, and resolution of patient grievances, complaints, and clinical appeals related to healthcare services provided within MEDIKO correctional facilities. This role ensures that all grievances and appeals are addressed in accordance with contractual obligations, regulatory requirements, accreditation standards, and internal policies.
</p><p>The Registered Nurse - Grievance and Appeals serves as a clinical resource supporting timely, thorough, and compliant grievance resolution processes while identifying trends and opportunities for system improvement. This position collaborates closely with facility leadership, medical providers, quality teams, and corporate leadership to ensure appropriate clinical review and response.</p><p>
How YOU can Make an Impact:</p><p>
Grievance and Complaint Management
</p><ul><li><p>Review, investigate, and resolve inmate/patient grievances related to healthcare services in accordance with established policies and contractual timelines.
</p></li><li><p>Conduct clinical assessments of complaints to determine appropriateness of care, adherence to standards, and required follow-up actions.
</p></li><li><p>Coordinate with facility clinical leadership, including Health Services Administrators, Directors of Nursing, and providers, to gather information related to grievances.
</p></li><li><p>Ensure timely and accurate documentation of grievance investigations and responses.
</p></li></ul><p>Clinical Appeals Review
</p><ul><li><p>Conduct clinical review of healthcare appeals related to treatment decisions, medication management, specialty referrals, and other medical services.
</p></li><li><p>Evaluate appeals against applicable clinical guidelines, policies, and standards of care.
</p></li><li><p>Collaborate with medical leadership to determine appropriate clinical determinations and responses.
</p></li><li><p>Prepare written appeal determinations that clearly explain clinical reasoning and outcomes.
</p></li></ul><p>Compliance and Regulatory Oversight
</p><ul><li><p>Ensure grievance and appeals processes comply with applicable regulations, accreditation standards, and contractual requirements.
</p></li><li><p>Monitor response timelines and ensure compliance with grievance response requirements.
</p></li><li><p>Maintain documentation necessary for audits, inspections, and accreditation reviews.
</p></li></ul><p>Quality Improvement and Reporting
</p><ul><li><p>Track and analyze grievance and appeals trends across facilities to identify systemic issues or opportunities for improvement.
</p></li><li><p>Prepare periodic reports for clinical leadership and compliance teams outlining trends, response metrics, and recommendations.
</p></li><li><p>Partner with operational and clinical leadership to implement corrective actions where appropriate.
</p></li></ul><p>Collaboration and Support
</p><ul><li><p>Serve as a clinical resource to facility leadership regarding grievance processes and appropriate responses.
</p></li><li><p>Provide guidance on documentation standards and complaint management practices.
</p></li><li><p>Support training and education efforts related to grievance handling and patient rights.
</p></li></ul><p>Documentation and Recordkeeping
</p><ul><li><p>Maintain accurate records of grievance and appeals investigations and outcomes.
</p></li><li><p>Ensure documentation is complete, defensible, and maintained in accordance with company policy and regulatory requirements.
</p></li></ul><p></p><ul><li><p>Perform other duties as assigned.
</p></li></ul><p>What we Ask of YOU:
</p><ul><li><p>A current, valid state(s) licensure, certificate and/or credentials documenting ability to practice in applicable role (i.e. CMA, LPN, RN, LMHP, etc.).
</p></li><li><p>A High School diploma or GED is required.
</p></li><li><p>An Associate&rsquo;s or Bachelor's degree in Healthcare, Nursing, or a related field is preferred but not required.
</p></li><li><p>1-3 years of experience in a healthcare setting, preferably in a correctional healthcare or similar environment.
</p></li><li><p>Experience in roles that involve direct patient care or administrative support in a regulated environment is preferred.
</p></li><li><p>Strong understanding of healthcare regulations, policies, and procedures as they relate to the correctional setting is an advantage.
</p></li><li><p>Demonstrated ability to manage time effectively, adhere to protocols, and deliver high-quality service in a fast-paced, structured environment.
</p></li><li><p>Active CPR/BLS certificate required (American Heart Association/American Red Cross guideline approved).
</p></li></ul><p>Joining <b>MEDIKO</b> comes with perks to support you in your personal and professional journey:
</p><ul><li><p>Competitive Pay and MVP Bonus Program</p></li><li><p>
Benefits package including Medical, Dental, and Vision insurance for you and your family</p></li><li><p>
Preferred Pharmacy Network options</p></li><li><p>
MDLIVE virtual Provider telehealth options</p></li><li><p>
Wellness program</p></li><li><p>
Health Savings Accounts and Health Reimbursement Account options with company match</p></li><li><p>
Employer-paid Life Insurance Policy/AD&amp;D, Long-Term Disability and Short-Term Disability coverage</p></li><li><p>
Optional Voluntary coverage for Life Insurance, Accident, Critical Illness, and Hospital Indemnity plans</p></li><li><p>
Paid portion of Maternity Leaves</p></li><li><p>
Employee Assistance Program</p></li><li><p>
Generous Paid Time Off (PTO) including 10 Holidays and flexible Floating Holidays</p></li><li><p>
Participation in the <b>MEDIKO</b> 401(k) Retirement Plan with company match</p></li><li><p>
Employee Referral Bonuses
</p></li><li><p>Tuition Reimbursement Assistance Plan</p></li><li><p>
Free Continuing Education</p></li><li><p>
Access to Perks and Discounts at nationally recognized chains, service providers and retailers</p></li></ul><p><i>
EOE STATEMENT: We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.</i></p></div>

Registered Nurse - Grievance and Appeals

Caloptima

<div><div><b>Grievance Resolution Specialist Sr (Provider Resolution)</b><br>
<br>
<b>CalOptima</b></div><br>
<b>
Join Us in this Amazing Opportunity</b><br>
<br>
<b>The Team You'll Join</b><br>
<br>
We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.<br>
<br>
<b>More About the Opportunity</b>
<br>
<br>
We are hoping you will join us as a <b>Grievance Resolution Specialist Sr (Provider Resolution)</b> and help shape the future of healthcare where you'll be an integral part of our <b>Grievance &amp; Appeals </b>team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be <b>Full Telework</b>.
<br>
<ul><li><i>If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.</i>
</li></ul><br>
You will coordinate the overall process of complaint resolution, responding to all verbal and written complaints from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. You will have frequent external contact with members and families, health care providers, organizations and regulators. In addition, you will frequently interact with internal contacts in Claims Administration, Customer Service, Provider Relations, Contracting, Pharmacy Management, Third-Party Administrators, Medical Management, health networks and other resources to identify the factors necessary for optimal resolution of complaints. You will be responsible for processing complex cases requiring additional research or problem-solving. You will process 1st and 2nd Level provider appeals in accordance with Department of Health Care Services (DHCS) and Centers for Medicare &amp; Medicaid Services (CMS) guidelines and regulations. Together, we are building a stronger, more equitable health system.
<br>
<br>
<b>Your Contributions To the Team:</b>
<br>
<ul><li>75% - Program Support
<ul><li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Develops and maintains adequate information systems to assure timely and effective data collection, summarization, integration and reporting, including case creation, management and events/activity tracking.</li>
<li>Ensures compliance with CalOptima Health's Grievance Policy and timely case resolution, initiates and coordinates referrals to the Quality Improvement department as necessary and facilitates response to members according to policy.</li>
<li>Handles escalated issues from providers, as well as internal and external customers.</li>
<li>Gathers pertinent information regarding complaints, including member or provider concerns, claims payments, billing reimbursements, supporting information related to initial decisions, new information supporting complaints and supplemental information required to evaluate complaints and regulatory requirements.</li>
<li>Coordinates and participates in case discussions with operational experts to result in a final case disposition.</li>
<li>Reviews government claim cases and determines resolution and recommendation based on researched claims, Provider Dispute Resolution (PDR) and 2nd Level appeal analyses.</li>
<li>Evaluates case details related to member or provider complaints and makes appropriate decisions based on information provided and research conducted.</li>
<li>Provides a summary of GARS cases requested by Legal Affairs or other departments.</li>
<li>Provides subject matter expertise and trains new and existing staff as needed.</li>
<li>Assists with case assignment, assumes cases assignments per business needs and monitors the daily operations for member and provider complaints, ensuring compliance with the implementation of the decision.</li>
<li>Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.</li>
<li>Oversees resolution letters for accuracy of information and appropriate decisions.</li>
<li>Meets performance measurement goals for GARS.</li>
Supports with provider appeals audits by reviewing findings, gathering and organizing requested materials and completing rebuttals.<br>
<li>
<br>
<br>
</li></ul></li><li>20% - Administrative Support
<ul><li>Participates in meetings regarding case assignment issues and collaborates with cross-department teams to maintain current knowledge of organizational processes and guidelines to effectively resolve cases.</li>
<li>Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.</li>
<li>Responds to routine provider inquiries via phone and assists with provider appeals resolution inquiries.</li>
<li>Tracks and trends provider appeals and claims issues.</li>
Supports all department initiatives in improving overall efficiency.<br>
<li>
<br>
<br>
</li></ul></li><li>5% - Completes other projects and duties as assigned.
</li></ul><br>
<b>Do You Have What the Role Requires?</b><br>
<ul>
<li>High school diploma or equivalent PLUS 3 years of experience with Provider Non-Contracted Medicare Post-Service appeals and denials required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.<br>
</li>
<li>3 years of experience with PDR in Medicare and Medi-Cal in Professional, Institutional, Outpatient, Ancillary, Coordination of Benefits and Government Cases required.
<br>
</li><li>Experience with Medicare or Medi-Cal provider appeals and denials process required.<br>
</li>
<li>Experience in health care practice standards, for both government and commercial plans required.<br>
</li>
<li>Experience with claims administration required.</li>
</ul><br>
<b>You'll Stand Out More If You Possess the Following:</b><br>
<ul>
<li>Associate's degree in health care administration or related field.<br>
</li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).</li>
</ul><br>
<b>What the Regulatory Agencies Need You to Possess?</b><br>
<ul>
<li>N/A</li>
</ul><br>
<b>Your Knowledge &amp; Abilities to Bring to this Role:</b><br>
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
</li><li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul><br>
<b>Your Physical Requirements (With or Without Accommodations):</b><br>
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul><br>
<b>Ways We Are Here For You</b><br>
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul><li>Our current hiring range is: Pay Grade: <b>306 - $58,205 - $90,217 ($27.98 - $43.3736).
</b><ul><li><b><i>The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.</i></b><br>
</li>
</ul></li></ul></li><li>This position is approved for <b>Full Telework </b><i>(**If the position is Telework, it is eligible in California only**)</i>
</li><li>A <b>comprehensive benefits package</b>
</li><li>CalPERS pension program and additional retirement packages.
</li><li>Additional benefits and perks including:
<ul><li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul></li></ul><br>
<b>Our Work Environment:</b><br>
<br>
If located at the 500, 505 Building or a remote work location:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul><br>
If located at PACE:<br>
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
If located in the Community:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
</li><li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
<b>Why Join Us?</b><br>
<br>
We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.<br>
<br>
<b>What's Your Next Step?</b><br>
<br>
All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is <b>April 1, 2026 at </b><b>9:00 PM (PST). </b><b>We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.</b>
<br>
<br>
<b>Our Commitment to You</b><br>
<br>
<b>Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.</b><br>
<br>
If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.<br>
<br>
We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.
<br>
<br>
<i>CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.</i><br>
<br>
<i>CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.</i><i>
</i><br>
<br>
<i>If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.</i><br>
<br>
<b>To apply, please visit: </b><b>https://jobs.caloptima.org/jobs/grievance-resolution-specialist-sr-provider-resolution-505-city-parkway-west-california-united-states</b><br>
<br>
jeid-9f97bae4154ec349812fc00e682610dd</div>

Grievance Resolution Specialist Sr (Provider Resolution)

Humana

<div><h1 class="jobSectionHeader"><b>Become a part of our caring community and help us put health first</b><br>
</h1>
The Grievances &amp; Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances &amp; Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.<p></p><p>
The Grievances &amp; Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.</p><h1 class="jobSectionHeader"><b><br>
Use your skills to make an impact</b><br>
<b>
</b></h1><p><b>Shift: Monday &ndash; Friday, 8am-5pm, but be flexible with your hours based on business needs to work possible overtime.</b></p><p><b>
The start date is in May. No time off will be allowed during training.
</b></p><p></p><p><b>Required Qualifications</b></p><ul><li>
2 years of customer service experience</li><li>
Must have experience in the healthcare industry or medical field</li><li>
Strong data entry skills required</li><li>
Intermediate experience with Microsoft Word and Excel</li><li>
Must have experience in a production driven environment</li><li><b>
Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance</b></li></ul><p></p><p><b>
Preferred Qualifications</b></p><ul><li>
Associate's or Bachelor's Degree</li><li>
Previous inbound call center or related customer service experience</li><li>
Grievance and appeals experience</li><li>
Previous experience processing medical claims</li><li>
Prior experience with Medicare</li><li>
Experience with the Claims Administration System (CAS)</li><li>
Knowledge of medical terminology</li><li>
Ability to manage large volume of documents including tracking, copying, faxing and scanning</li><li>
Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population</li></ul><p></p><p><b>
Additional Information</b></p><p></p><p><b>
Work at Home Guidance</b></p><p>
To ensure Home or Hybrid Home/Office associates&rsquo; ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:</p><ul><li>
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.</li><li>
Satellite, cellular and microwave connection can be used only if approved by leadership.</li><li>
Associates who live and work from Home in the state of Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.</li><li>
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.</li><li>
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.</li></ul><p></p><p><b>
Interview Process</b></p><p>
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.</p><ul><li><b>
Assessment: </b>If you are selected to move forward, you will receive an email to complete the Virtual Job Experience (VJE). This is an online activity where you will learn more about Customer Care jobs at Humana, try out some of the most common job tasks, and tell us more about yourself. Most people complete the VJE in approximately 30 minutes. To complete it, you will need a smart phone, computer or tablet with internet access, and speakers/headphones. We do not make job offers to candidates that do not complete the VJE.</li><li><b>
Video Prescreen</b>: If you are successful with your text screen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.
</li><li><b>Interviews</b>: Some candidates will be invited to interview. If so, the recruiter will reach out to schedule.</li><li><b>
Offers</b>: Finalists from the interview will be contacted by a recruiter to discuss an offer for the job.</li><li><b>
Note</b>: Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.</li></ul><p></p>
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.<p></p><p><b>
Scheduled Weekly Hours</b></p><p></p>
40<p></p><p><b>
Pay Range</b></p>
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.<br>
<p></p>
$34,400 - $45,000 per year<p></p><p><b><br>
Description of Benefits</b></p>
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.<p></p><h1 class="jobSectionHeader"><b><br>
About Us</b><br>
</h1>
Humana Inc. (NYSE: HUM) is committed to putting health first &ndash; for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.<p></p><p><br>
<br>
<b>Equal Opportunity Employer</b></p><p></p><p>
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.</p></div>

Grievances & Appeals Representative

Powerback Rehabilitation

<div>Overview:
<div><b>
FULL-TIME (REMOTE) CORPORATE DENIALS &amp; APPEALS SPECIALIST</b></div><div></div><div><b><br>
MUST HAVE HEALTHCARE BILLING/COLLECTIONS EXPERIENCE W/CONCENTRATION ON DENIALS / APPEALS</b></div><div></div><div><br>
At Powerback, we're on a mission to improve lives. As the leader in physical, occupational, speech, and respiratory therapies, we help older adults stay active and thrive while providing essential therapy for children at home and in school.</div><div></div><div><br>
With over 38 years of trusted service, our reach spans skilled nursing centers, assisted and independent living facilities, outpatient clinics, and home-based care. We're proud to deliver personalized care exactly where and when it's needed most.</div><div></div><div><br>
Join an industry-leading team that restores hope and makes a lasting impact. If you're passionate about making a meaningful difference and want to be part of the future of rehabilitation and wellness, Powerback is the place for you.</div><div></div><div><b><br>
Why Powerback?</b></div><ul><li><b>
Benefits:</b> We offer Medical, Dental, and Vision plans to Full-Time team members. We offer Dental and Vision to Part-Time team members.</li><li><b>
Paid Time Off</b>: We offer generous paid time off to Full-Time and Part-Time team members.</li><li><b>
Support for New Grads:</b> Our Powerback Clinical Mentorship Program kicks off on day one, helping you learn from the best in the field.</li><li><b>
Continuing Education:</b> Keep growing with free CEUs through Medbridge.</li><li><b>
H-1B Visa &amp; Relocation Assistance:</b> We support Visa or Green Card sponsorships, plus our Journey Travel Program lets you work across the U.S. with the security of a full-time role.</li><li><b>
Perks at Powerback:</b> Enjoy exclusive discounts on Wireless/TV, Home/Auto/Renters and Pet Insurance, Childcare, Eldercare, and more. Earn rewards through our PowerZone Employee Recognition Program, and expand your expertise with our Clinicians in Action professional development program</li></ul>
Responsibilities:
<div><div>The Denials and Appeals Specialist is responsible for the follow up of denied claims from all commercial and contracted payers. The follow up includes initial assessment of the denials received to determine the appropriate process. Once determined, established policy and procedure will be followed for appeal submission.</div><div><br>
Reviews assigned accounts that have a payer denial based on the response from the payer and takes appropriate action, including appeals, based on the type of denial.</div><div>
Documents all necessary elements; reason for denial/audit, denial status, and action taken in the electronic medical record per denial management policy.</div><div>
Provides missing or additional information if necessary, to expedite the resolution of the denied claim. This may include writing detailed appeal letters supporting the claim and reimbursement.</div><div>
Performs all appeals and denials recovery procedures needed to appropriately and accurately resolve denied claims. This includes working with internal and external customers.</div><div>
Consistently meets productivity and quality standards established by management, recommending new approaches for enhancing performance and productivity when appropriate.</div><div>
Keeps Supervisor/Manager informed of any problems or issues related to the appeal process and/or current appeals.</div><div>
Performs other duties as assigned.</div></div>
Qualifications:
<div><ul><li>High School diploma or equivalent education and experience required. College degree preferred.</li><li>Must be proficient using MS Office or Google Suite applications.</li><li>Strong analytical skills.</li><li>Minimum of 1 - 2 years of previous revenue cycle management experience.</li></ul></div>
Posted Salary Range: USD $20.00 - USD $20.00 /Hr.</div>

Denials and Appeals Specialist

Mutual of Omaha

<div><div><p><b>Location:</b> Remote<br>
<b>Work Type:</b> Full Time Regular<br>
<b>Job No:</b> 504643<br>
<b>Categories:</b> Claims/Claims Processing<br>
<b>Application Closes:</b> Closes Mar 31, 2026
</p><div>2026-03-13</div></div><div></div><div><br>
</div><div></div><div><div><div><div><div>In this role, you&rsquo;ll leverage your expertise in claims adjudication, contract interpretation, and risk management to guide clients, overcome obstacles, and ensure fair, compliant decisions. You&rsquo;ll collaborate with internal teams and the Law Division, communicate clearly and professionally with claimants and stakeholders, and manage multiple priorities with accuracy and attention to detail. This role also offers the opportunity to mentor and support staff while continuously improving processes and efficiency.</div></div><br>
<div>
<div><p><b>WHAT WE CAN OFFER YOU:</b></p>
<div>
<ul><li>Estimated Salary: (Levels have variable responsibilities and qualifications):
<ul><li>Appeals Specialist: $54,000 - $66,000 plus annual bonus opportunity.
</li><li>Sr Appeals Specialist: $68,000 - $90,000 plus annual bonus opportunity.
</li></ul></li><li>401(k) plan with a 2% company contribution and 6% company match.
</li><li>Work-life balance with vacation, personal time and paid holidays. See our benefits and perks page for details.
</li>Applicants for this position must not now, nor at any point in the future, require sponsorship for employment.<br>
<li>
</li></ul></div></div></div><br>
<div><div><p><b>WHAT YOU'LL DO:</b></p>
<div>
<ul><li>Reviews and evaluates all pre- and post-adverse benefit determination materials for Group STD, LTD, Life, AD&amp;D, Waiver of Premium, CI and Accident appeals; overcomes objections through effective appeal arguments, escalates appropriately, and requests additional information as needed to clarify issues.</li>
<li>Renders appeal decisions using medical, vocational and legal risk management resources; serves as a technical expert to guide client appeal activities and leverages contract language to support sound determinations.</li>
<li>Prepares clear, professional written communications to claimants, representatives, policyholders, brokers and attorneys; documents actions thoroughly and maintains accurate records of appeal cause, disposition and trending.</li>
<li>Ensures compliance with ERISA and applicable federal and state laws; researches and evaluates emerging case law and regulatory changes, presents cases in forums, and remains current on company, industry and legislative updates.</li>
Drives continuous improvement by identifying technological and process enhancements; mentors and trains staff and clients on appeals and risk management, contributes to internal policy development, and partners with operations to ensure alignment on key processes.<br>
<li>
</li></ul></div></div></div><br>
<div><div><p><b>WHAT YOU&rsquo;LL BRING:</b></p>
<div>
<ul><li>Minimum of 10 years of Group Disability experience, thorough understanding of claims adjudication, benefit determination, investigation, file development, legal requirements, and contract interpretation, with the ability to conduct focused and extensive claims research.</li>
<li>Demonstrated high-level risk management, analytical, mathematical, problem-solving, and decision-making skills, with strong persuasion, negotiation, and ability to interpret and communicate disability contract language.</li>
<li>Excellent communication skills with the ability to remain professional and pleasant in interactions with coworkers, clients, claimants, vendors, and others; capable of conducting small group presentations and collaborating with the Law Division, including potential participation in depositions or trials.</li>
<li>Ability to de-escalate situations on a regular basis and manage multiple priorities effectively.</li>
<li>Superior attention to detail, flexibility, and the ability to work independently or as part of a team.</li>
<li>You promote a culture of diversity and inclusion, value different ideas and opinions, and listen courageously, remaining curious in all that you do.</li>
<li>Able to work remotely with access to a high-speed internet connection and located in the United States or Puerto Rico.</li></ul></div><br>
</div>
</div><br>
<div><div><p><b>We value diverse experience, skills, and passion for innovation. If your experience aligns with the listed requirements</b></p>
<p>
If you have questions about your application or the hiring process, email our Talent Acquisition area at careers@mutualofomaha.com. Please allow at least one week from time of applying if you are checking on the status.</p>
<p><b>
Stay Safe from Job Scams</b><br>
Mutual of Omaha only accepts applications from mutualofomaha.com/careers. Legitimate communications will come from '@mutualofomaha.com.' We never request sensitive information or extend job offers without conducting interviews. For more details, check our Hiring FAQs. Stay alert for scams and apply securely!</p>
<p>
Fair Chance Notices</p>
</div>
</div><br>
</div></div></div><div>Need help? Email Us
</div><div><div><h2 class="jobSectionHeader"><b>Great place to work</b></h2>
<p>Together we achieve greatness. Not only is this a core value, but it&rsquo;s also representative of the kind of place we are &mdash; built by the strength and integrity of our employees. It&rsquo;s why we&rsquo;re named a &ldquo;Great Place to Work&rdquo;.</p><br>
<p></p>
</div><div><h2 class="jobSectionHeader"><b>An inclusive culture</b></h2>
<p>Surround yourself with an authentic and inclusive culture. Your strengths and differences will be valued and celebrated by a diverse community of co‑workers.</p></div></div></div><p></p>

Appeals Specialist (Group Claims)

Temp Experts

<div><b>Revenue Cycle Management Appeals Specialist</b><br>
<b>Clearwater, FL</b><br>
<b>Onsite | Full-time</b><br>
<br>
TempExperts is seeking<b> </b>motivated professionals for a <b>long-term Revenue Cycle Management project</b> with a rapidly growing medical technology organization in <b>Clearwater, FL</b>. This is an excellent opportunity to make a real impact on patients&rsquo; lives, gain valuable healthcare industry experience, and work in a collaborative, mission-driven environment offering stability and long-term potential. The role focuses on helping cardiac and orthopedic patients access life-changing medical products and resolving insurance claims.<br>
<br>
<b>Responsibilities:</b>
<ul><li>Manage and resolve denied insurance claims through detailed appeals.
</li><li>Contact insurance carriers to determine reasons for denials and pursue resolution.
</li><li>Research, analyze, and document claim information accurately and efficiently.
</li><li>Collaborate with internal departments to gather and submit supporting documentation.
</li><li>Track appeal outcomes and maintain organized, up-to-date records.
</li></ul><b>Requirements/Education:</b>
<ul><li>Confident, professional communicator comfortable resolving issues by phone.
</li><li>Determined, goal-oriented, and accountable individual.
</li><li>Adaptable and comfortable in a fast-paced environment.
</li><li>Detail-oriented with strong multitasking and prioritization skills.
</li><li>Dependable team player who thrives on achieving results.
</li></ul><i>TempExperts is an Equal Opportunity Employer.</i></div>

Revenue Cycle Management Appeals Specialist

Clever Care Health Plan

<div>
 Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California&rsquo;s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
 <br/>
 <br/>
 Who Are We? ✨
 <br/>
 <br/>
 Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members&rsquo; culture and values.
 <br/>
 <br/>
 Why Join Us? 🏆
 <br/>
 <br/>
 We&rsquo;re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you&rsquo;ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
 <br/>
 <br/>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 The Clinical Review Nurse evaluates medical records and clinical documentation to support the resolution of claims, member grievances, appeals, and quality-of-care concerns. Using clinical judgment and appropriate application of CMS regulations, Medicare Advantage requirements, and evidence-based guidelines, this role conducts retrospective clinical reviews and prepares complete, accurate, and audit-ready case files for Medical Director review and determination.
 <br/>
 <br/>
 Claims are defined as:
 <br/>
 <br/>
 <ul>
  <li>
   Initial payment determinations for covered Part C and Part D services
  </li>
  <li>
   Post-service claims requiring clinical review to support payment accuracy and benefit application
  </li>
  <li>
   Claims requiring medical necessity, level-of-care, or appropriateness-of-care assessment
  </li>
  <li>
   Claims involving retrospective review of medical records or clinical documentation
  </li>
  <li>
   Provider payment disputes requiring clinical validation (non-appeal)
  </li>
  <li>
   High-dollar, complex, or high-risk claims requiring clinical review prior to final determination
  </li>
  <li>
   Claims requiring coordination with Medical Management, Claims Operations, or Medical Director review
   <br/>
   <br/>
  </li>
 </ul>
 Appeals and Grievances are defined as:
 <br/>
 <br/>
 <ul>
  <li>
   Organization Determinations / Coverage Requests (pre-service)
  </li>
  <li>
   Part C reconsiderations (standard &amp; expedited)
  </li>
  <li>
   Part D redeterminations/coverage determinations (if applicable)
  </li>
  <li>
   Payment disputes/claim appeals (if in scope)
  </li>
  <li>
   Quality of Care grievances
  </li>
  <li>
   Appeal withdrawals/dismissals &amp; validity checks (authorized rep, timeliness, etc.)
   <br/>
   <br/>
  </li>
 </ul>
 The Clinical Review Nurse applies clinical acumen to assess medical necessity, appropriateness of care, and quality of services rendered; documents findings in designated medical management systems; and collaborates with non-clinical staff to ensure timely, compliant, and defensible case resolution.
 <br/>
 <br/>
 <strong>
  Essential Functions &amp; Job Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Provide clinical review support for claims, claim appeals, grievances, provider disputes, and quality of care grievances, including retrospective review of medical records and claims.
  </li>
  <li>
   Conduct clinical reviews to assess medical necessity, appropriateness of care, and quality of services rendered, using clinical judgment and applicable CMS guidelines, Medicare manuals, and plan policies.
  </li>
  <li>
   Prepare clear, concise clinical summaries and recommendations for Medical Director review, including identification of key clinical facts, regulatory considerations, and applicable coverage or clinical criteria.
  </li>
  <li>
   Support the preparation and review of Quality of Care (QOC) grievance cases for Medical Director evaluation, including identification of potential care issues, documentation gaps, and quality concerns.
  </li>
  <li>
   Apply nationally recognized clinical decision support tools and guidelines (e.g., InterQual, MCG, NCDs/LCDs, specialty society guidance) as applicable to clinical reviews.
  </li>
  <li>
   Review and interpret medical coding and billing information (CPT, HCPCS, ICD-10-CM/PCS, DRG, Revenue Codes) to support accurate clinical assessment.
  </li>
  <li>
   Identify missing or insufficient clinical documentation and coordinate with providers or internal departments to obtain additional information.
  </li>
  <li>
   Enter, maintain, and validate clinical documentation and review outcomes in medical management and case tracking systems.
  </li>
  <li>
   Ensure cases are prepared and routed within required CMS and contractual turnaround timeframes; maintain awareness of standard vs expedited timeframes and tolling requirements when records are pending.
  </li>
  <li>
   Escalates risks to prevent late determinations; escalates cases at risk of noncompliance same day when barriers arise (missing records, invalid auth rep, misrouted cases).
  </li>
  <li>
   Respond accurately and timely to Medical Directors, Claims, Appeals and Grievances staff, and other internal stakeholders regarding clinical findings.
  </li>
  <li>
   Assist with CTM-related clinical case review and provide clinical input to support compliant complaint resolution.
  </li>
  <li>
   Participate in audit readiness activities, including case file review, universe validation, and response to regulatory or oversight entity requests.
  </li>
  <li>
   Audit clinical reviews to ensure compliance with Claims, Appeals and Grievances, and medical management policies and procedures.
  </li>
  <li>
   Provide clinical guidance and act as a clinical resource to non-clinical staff.
  </li>
  <li>
   Participate in special projects related to Claims, Appeals and Grievances operations, quality improvement, or regulatory compliance.
  </li>
  <li>
   Participate in required training and assist with onboarding and education of new or existing staff as needed.
  </li>
  <li>
   Ensures all case documentation supports CMS audit and legal defensibility, including record inventory, clinical criteria citations, decision rationale, and accurate system time stamps.
  </li>
  <li>
   Differentiates and prioritizes standard vs expedited requests and applies tolling/extension rules as applicable per policy.
  </li>
  <li>
   Maintains HIPAA compliance and secure handling of PHI in all systems and remote work environments.
  </li>
  <li>
   Other duties as assigned.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Education &amp; Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Graduate from an accredited school of nursing
  </li>
  <li>
   Active, unrestricted RN or LVN/LPN license
  </li>
  <li>
   Must hold a current CCS or CPC certificate; both are preferred
  </li>
  <li>
   Three (3) or more years of Appeals and Grievances and/or Utilization Management experience within a Health Plan, IPA, MSO, or managed care environment
  </li>
  <li>
   Demonstrated experience supporting Medicare Advantage Appeals and Grievances, including clinical appeal review and Medical Director case preparation
  </li>
  <li>
   Two (2) or more years of direct clinical nursing experience
  </li>
  <li>
   Knowledge of Medicare Advantage regulations related to claims, appeals, grievances, and quality of care reviews
  </li>
  <li>
   Experience applying clinical decision support tools (e.g., InterQual, MCG, NCDs/LCDs) and evidence-based guidelines
  </li>
  <li>
   Familiarity with medical coding and billing concepts (CPT, HCPCS, ICD-10, DRG, Revenue Codes)
  </li>
  <li>
   Knowledge of regulatory timelines to ensure compliance with CMS and state requirements
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Skills
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Strong clinical judgment and analytical skills
  </li>
  <li>
   Strong organizational skills with the ability to manage multiple cases and deadlines
  </li>
  <li>
   Excellent written and verbal communication skills, including clinical summary preparation
  </li>
  <li>
   Strong attention to detail and documentation accuracy
  </li>
  <li>
   Proficiency with Windows-based applications and Microsoft Office (Word, Excel, PowerPoint)
  </li>
  <li>
   Ability to adapt to new systems and regulatory requirements
  </li>
  <li>
   Excellent typing and documentation skills
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Wage Range:
 </strong>
 $38.46 to $48.00 per hour DOE and License
 <br/>
 <br/>
 <strong>
  Physical &amp; Working Environment.
  <br/>
  <br/>
 </strong>
 Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
 <br/>
 <br/>
 <ul>
  <li>
   Must be able to travel when needed or required
  </li>
  <li>
   Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (notetaking)
  </li>
  <li>
   Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
   <br/>
   <br/>
  </li>
 </ul>
 Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
 <br/>
 <br/>
 Work is performed in an office environment and/or remotely. When working remotely, the workspace must be HIPAA compliant:
 <br/>
 <br/>
 <ul>
  <li>
   HIPAA/PHI handling, minimum necessary access
  </li>
  <li>
   Secure remote work expectations (private workspace, locking screens, secure network, no printing unless authorized, etc.)
   <br/>
   <br/>
  </li>
 </ul>
 The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
 <br/>
 <br/>
 <em>
  Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
  <br/>
  <br/>
 </em>
 <em>
  Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate&rsquo;s state residency.
 </em>
</div>


Grievance and Appeals Clinical Review Nurse (RN/LVN)

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