- Zelis (St. Petersburg, FL)
- …role with production and quality metric goals. What you'll do: + Review provider disputes for DRG Coding and Clinical Validation (MS and APR) ... and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales + Perform… more
- ChenMed (Miami, FL)
- …to join our team. The Physician Reviewer is the primary physician reviewer for Utilization Management/ Clinical Appropriateness review cases in our ... for our patients. The position will also participate in Process and Quality improvement in our developing area of Delegated Utilization Management. **ESSENTIAL JOB… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The ... your true colors to blue. The Role The Physician Reviewer is responsible for evaluating clinical service...anticipatory case management for members whose cases come for review , in partnership with case managers + Participate in… more
- AmeriHealth Caritas (Washington, DC)
- …determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care ... When necessary, cases are escalated to the Medical Director for further review . The reviewer independently applies medical and behavioral health guidelines… more
- Evolent (Lansing, MI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …gather clinical information to support the plan of care. + Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality ... use of the member's benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. +… more
- Ochsner Health (Slidell, LA)
- …surgeries in the hospital. Works closely with Departments to identify opportunities for clinical quality improvement and other special projects as may be ... assumes responsibility for managing all facets of the National Surgical Quality Improvement Program (NSQIP) database which is a nationally validated, risk-adjusted,… more
- Bristol Myers Squibb (Summit, NJ)
- …investigation experience. **Duties and Responsibilities:** + Supports all activities for the Quality Operations Investigations group. + Review and approve Site ... + Review and approve Supplemental actions. + Review and approve Impact assessments or Product Quality...also be limited for the capability centers. Employees in remote -by-design or lab-based roles may be eligible for summer… more
- Zelis (FL)
- …found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review + Document all aspect of audits ... interests that shape who you are. Position Overview The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay… more
- Chenega Corporation (Rockville, MD)
- …Strategic Business Unit** company, is looking for a Nurse Practitioner-Contract Medical Reviewer (CMR) to support the Department of Health and Human Services (HHS), ... Compensation Program (CICP). Ideal candidates bring 5+ years of recent, hands-on clinical experience and strong familiarity with outpatient medicine, as this aligns… more
- The Joint Commission (Oakbrook Terrace, IL)
- …Field Representatives, with minimal direction or supervision, survey and/or review health care organizations throughout the United States. Field Representatives ... **Responsibilities** Position Accountabilities: + Ability to analyze and synthesize survey/ review findings to provide conclusions, recommendations and educational opportunities.… more
- Zelis (NJ)
- …responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved ... records utilizing ICD-10 Official Coding Guidelines, AHA Coding Clinic evidence based clinical criteria and client specific coverage policies. What you'll do: +… more
- UCHealth (Aurora, CO)
- Description This position is an onsite role and does not offer a hybrid or remote option. UCHealth Clinical Quality and Safety Specialist (CQSS) - Safety * ... review and response Location: UCHealth UCHlth Leprino Building AMC, US:CO:Aurora Department: Clinical Quality FTE: Full Time, 1.0, 80.00 hours per pay period… more
- Martin's Point Health Care (Portland, ME)
- …Summary The Supervisor is responsible for day-to-day operations of the utilization review clinical team, in the areas of authorization requests, organizational ... Board of Managed Care Nursing (ABMCN), National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services...management experience in a managed care setting including utilization review + RN experience in a clinical … more
- Trinity Health (Livonia, MI)
- …and proper documentation requirements as it relates to reimbursement and other clinical data quality management for colleague training. Provides quality ... and quality outcomes. Serves as a resource for appropriate clinical documentation. Responsible for scheduling and staffing assignments for the Clinical… more
- Cedars-Sinai (Beverly Hills, CA)
- …surpluses. Negotiates with sponsors the final payment due for account closeout. May conduct review and/or audits of clinical trial budgets. Serves as a resource ... trial budget. + Performs Medicare coverage analysis for clinical trials and collaborates with Institutional Review ...improve existing standard operating procedures related to budgeting and clinical trials finance. May identify quality and… more
- UTMB Health (Galveston, TX)
- QAPI Clinical Service Ln Mgr (RN) Partial Remote (Sealy Heart & Vasc. Inst. - Galveston) **Galveston, Texas, United States** Nursing & Care Management UTMB ... + Sound working knowledge of concepts, practices, and procedures related to quality improvement functions specific to clinical program supporting. + Demonstrated… more
- Molina Healthcare (WI)
- … Validation is a plus. Work hours: Monday - Friday 8:00am- 5:00pm Remote position **Essential Job Duties** * Performs clinical /medical reviews of previously ... JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for internal appeals...provided to members. Contributes to overarching strategy to provide quality and cost-effective member care. We are seeking a… more
- Terumo Neuro (Aliso Viejo, CA)
- …+ Draft study-specific Monitoring Plans in collaboration with a Project Manager and Clinical Quality Assurance. + Assume Lead Clinical Research Associate ... **12869BR** **Title:** Sr Associate, Field Clinical Monitoring (US Remote ) **Job Description:**...of delivering start-up goals, enrollment targets, and required data quality . + Facilitate and maintain open communication among investigational… more
- CVS Health (Phoenix, AZ)
- …to promote quality effectiveness of healthcare services and benefit utilization. ** Remote Work Expectations** + This is a 100% remote role; candidates ... Schedule: Monday-Friday 8:00am-5:00pm AZT (No weekends or holidays) Location: 100% Remote (Must have Arizona RN license or compact license that includes… more