- Kepro (AR)
- … to join our growing team. Job Summary: The Dental Physician Reviewer -Oral Surgeon will oversee utilization review /management activities to include peer ... related to the applicable contract. The Oral Surgeon Physician Reviewer will support the dental UM contract for Arkansas...Case and Disease Management with knowledge of Medicaid and Medicare programs. + Prior review experience or… more
- Commonwealth Care Alliance (Boston, MA)
- …under the provisions of CCA's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization ... review for medical necessity and decision-making. The Utilization Management Reviewer has a key role in ensuring CCA meets CMS compliance standards in the area of… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Clinical Quality Nurse Reviewer RN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position ... achieve that purpose. Job Summary The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM) Department… more
- Centers Plan for Healthy Living (Margate, FL)
- UM Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #664 Monday, September 9, 2024 Centers Plan for Healthy Living's goal is to create the ultimate ... for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a multidisciplinary team to help identify and manage… more
- Zelis (Morristown, NJ)
- Position Overview: The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical ... billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical… more
- Kepro (Nashville, TN)
- …Preferred Qualifications/Experience: + Working knowledge of quality assurance and utilization review . + Experience with Medicaid/ Medicare . + Prior managed ... sector. Acentra is looking for a Physician Medical Claims Reviewer to join our growing team. Job Summary: The...+ Prepare independent reviews of medical services appeals. + Review records, prepare and submit all reviews in keeping… more
- Kepro (Lombard, IL)
- …for health solutions in the public sector. Acentra seeks a Psychiatrist Physician Reviewer (Illinois Remote, PRN) to join our growing team. Job Summary: The ... Psychiatrist Physician Reviewer will provide principal leadership and clinical expertise to...and clinical expertise to operations relating to the peer review process, utilization review activities, and other… more
- Commonwealth Care Alliance (Boston, MA)
- …the provisions of CCA's benefits plan. The Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization ... review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA meets CMS compliance standards in the… more
- Zelis (TX)
- Position Overview: The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews ... AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for… more
- UCLA Health (Los Angeles, CA)
- …Medicine Clinical Trial Program is seeking a skilled Clinical Trial Charge Reviewer to examine, correct, and consistently update billing information to ensure ... CPT coding rules; the mechanics of HMO's and IPA's and PPO's; Medicare /Medicaid regulations; proper billing methods; applicable fair debt and collection laws;… more
- Granville Health System (Oxford, NC)
- …for Medicaid or other account needs to correct patient outstanding balances Review all Medicare and Medicaid overpayments creating credit balances and ... accounts as they are processed by insurance.# Logs all Medicare crossover bad debts on the appropriate logs.# Works...Medicaid on the appropriate bad debt logs for processing Review and process returned mail by searching for updated… more
- Centene Corporation (Madison, WI)
- …is strongly preferred. **Position Purpose:** Perform clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive ... review and analysis of medical claims, medical records, claims...by the American Medical Association and the Centers for Medicare and Medicaid Services. + Analyze provider billing practices… more
- Humana (Columbus, OH)
- …of our caring community and help us put health first** The Group Medicare Proposal Development/Contract Review Professional 2 reviews solicitations and prepares ... simple requests for proposals (RFPs)/request for renewals (RFRs). The Group Medicare Proposal Development/Contract Review Professional 2 is primarily responsible… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... us on Facebook, Twitter and LinkedIn. **Responsibilities** The Chart Review Specialist primary responsibility is to review ,...Chart Review Specialist primary responsibility is to review , analyze and report on FCHP patient charts for… more
- Medical Mutual of Ohio (OH)
- …remediation efforts for Hospice and End Stage Renal Disease (ESRD) processes. . Supports Medicare Pharmacy Specialists in the research and review of Part D and ... providing confirmation of compliance to internal team. . Supports Medicare Pharmacy Specialists in the research and review... Medicare Pharmacy Specialists in the research and review of Part D and Part B inquiries, grievances,… more
- Elevance Health (Smithfield, RI)
- … of complex exception requests and CMS change requests. + Perform supervisory review of workload involving complex areas of Medicare part A reimbursement ... **Audit & Reimbursement Senior -** ** Medicare Cost Report Audit** **Locations:** _This is a...will make an impact:** + Prepare and perform supervisory review of cost report desk reviews and audits. +… more
- Humana (Miami Lakes, FL)
- …exceed $115K depending on experience and location. Are you passionate about the Medicare population, looking for an opportunity to work in sales, and wanting the ... join our team. Do you have 2+ years of Medicare Sales experience in the **field** ? If so,...and therefore subject to driver license validation and MVR review . **Schedule:** Meeting with members requires appointments and/or event… more
- AdventHealth (Altamonte Springs, FL)
- …and responding to audit findings in a timely and efficient manner . Update, review , and maintain supporting documentation for the Medicare and Medicaid Uniform ... of work papers for the filing of the annual Medicare , Medicaid, and Champus/Tricare cost reports, audit preparation and...of third party balances of Adventist Health System . Review the reasonableness of hospital interim reimbursement rates and… more
- General Dynamics Information Technology (Fairfax, VA)
- …NACI (T1) **Job Family:** Data Analysis **Skills:** Data Analysis,Healthcare Analytics, Medicare , Medicare Advantage,Researching **Experience:** 8 + years of ... related experience **Job Description:** As a Medicare Advantage Analytics Advisor you will help ensure today...and accident insurance are provided or available. We regularly review our Total Rewards package to ensure our offerings… more
- CVS Health (Lansing, MI)
- …manner. **Group Retiree Solutions** (GRS) is a core component of the Aetna Medicare Organization. Our vision is to develop an industry-leading group retiree health ... are seeking an Executive Director to lead the newly formed **Group Medicare Performance Optimization** team. This leader will preside over performance management… more