- MetroHealth (Cleveland, OH)
- …appropriate and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the appropriateness of ... Current Registered Nurse License State of Ohio. Minimum of 5 years clinical experience. Knowledge and experience with medical necessity criteria for inpatient… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Tuesday, November 5, 2024 Centers Plan for Healthy Living's ... plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial Adverse… more
- Guthrie (Binghamton, NY)
- …for prior authorization/certification for reimbursement of patient care services. The Utilization Reviewer : * Secures authorization as appropriate * Documents ... Utilization Management (Days) Full Time Position Summary: The Utilization Management (UM) Reviewer , in collaboration with...to track and monitor the status for denials and appeals . c) Collects and aggregates clinical , financial,… more
- Prime Therapeutics (Columbus, OH)
- …fuels our passion and drives every decision we make. **Job Posting Title** Physician Clinical Reviewer - GI- REMOTE **Job Description Summary** Key member of the ... utilization management team, and provides timely medical ...clinical determinations cannot be made by the Initial Clinical Reviewer . + Discusses determinations with requesting… more
- Evolent Health (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Physician Clinical Reviewer you will be a key member of the utilization ... when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the… more
- Evolent Health (Columbus, OH)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer , you will be a key... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- Kepro (AR)
- …include peer review , utilization review , fair hearings and appeals , and other clinical consultations related to the applicable contract. The Oral ... join our growing team. Job Summary: The Dental Physician Reviewer -Oral Surgeon will oversee utilization review... Management reviews or clinical scenarios with Utilization Management Dental Hygienist Reviewers. + Review … more
- ManpowerGroup (Columbia, SC)
- …+ Ensure thorough documentation of each determination for utilization or claims review . + Review first-level appeals and provide accurate basis for ... of medical claims review processes, medical necessity guidelines, and utilization review practices. + Proficiency in medical terminology, coding procedures,… more
- ManpowerGroup (Columbia, SC)
- …" to join one of our Fortune 500 clients. **Job Summary** The Medical Review and Utilization Management Specialist is responsible for performing medical reviews ... **Title: Medical Reviewer ** **Location:** **4101 Percival Road Columbia SC 29229...appeals . This role involves documenting decisions based on clinical guidelines, providing support for medical claims reviews, and… more
- Sharp HealthCare (San Diego, CA)
- …**What You Will Do** The position is responsible for the performing medical utilization reviews and appeals and grievance reviews under the direction of ... Functions** + Physician Responsibilities + Performs Medical Necessity Reviews including utilization management and appeals and grievances. Assists physician team… more
- Banner Health (AZ)
- …on your experience as a Registered Nurse and your knowledge of Case Managment and Utilization Management to review clinical records to ensure patients are in ... or other staff of non-company locations on concurrent and retrospective utilization review . Accurately and thoroughly completes documentation required for… more
- Centene Corporation (New York, NY)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... York State clinical license.** **Position Purpose:** Performs clinical reviews needed to resolve and process appeals...analyzing the basis for the appeal + Ensures timely review , processing, and response to appeal in accordance with… more
- ManpowerGroup (Columbia, SC)
- …while ensuring compliance with guidelines and protocols. **Key Responsibilities:** **Medical and Utilization Review (80%)** : + Conduct medical reviews using ... coverage. + Document decisions accurately, following protocol sets or clinical guidelines. + Review and approve or...). + Knowledge of medical terminology, claims processing, and utilization review protocols. + Strong documentation and… more
- VNS Health (Manhattan, NY)
- …and appeals or related area such as medical or utilization management required + Proficient verbal/written communication skills required + Proficient computer ... OverviewResolves grievances, appeals and external reviews for one of the...of the plan's fiduciary responsibilities. Prepares records for physician review as needed. + Conducts review of… more
- CDPHP (Albany, NY)
- …requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render ... you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering... experience required. + Minimum one (1) year of quality/ utilization review experience required. + Experience with… more
- VNS Health (Manhattan, NY)
- …You Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. ... quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of...Appeals or related area such as medical or utilization management in a Managed Care setting required +… more
- LA Care Health Plan (Los Angeles, CA)
- …Business. Duties Work with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares ... and Grievances Nurse Specialist LVN II Job Category: Clinical Department: CSC Appeals & Grievances Location:...Summary for MD review and determination. Performs clinical review of medical records related to… more
- Elevance Health (Indianapolis, IN)
- …+ Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. + ... **Title: Grievance/ Appeals Analyst I** **Location:** This position will work...HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of… more
- Elevance Health (Los Angeles, CA)
- …+ Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. + ... **Title: Grievance/ Appeals Analyst I** **Location:** This position will work...HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of… more
- CVS Health (Salem, OR)
- …to support 24/7 appeals work * IRE monitoring and tracking and Utilization Management Strategy support * Develop subject matter expertise on Medicare policy for ... the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff * Participate in… more