- Community Health Plan of Washington (Medford, OR)
- …and Roles and Responsibilities: * Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health ... services. * Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing care. * Delivers timely written notification to patient… more
- CVS Health (Lansing, MI)
- …schedule 8a-5pm Est time.) No travel is required.Applicants from any state can apply. Prior Authorization UM Nurse Consultant Utilizes clinical ... in state of residence 3+ years of Nursing experiencePreferred Qualifications Prior authorization utilization experience preferred Outpatient Clinical experience… more
- CVS Health (Carson City, NV)
- …required 3 weeks training required 100% participation during 8:30am-5pm EST Monday-Friday As a UM Nurse Consultant you will work in a clinical telephone queue ... working with providers to secure additional information for prior authorization reviews. -This candidate will utilize clinical skills to coordinate, document and… more
- Molina Healthcare (New York, NY)
- …**We are looking for a RN Care Review Clinician with Prior Authorization experience. Candidates with Utilization Management ( UM ) and MLTC/LTC experience are ... and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility...teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other… more
- Evolent Health (Columbus, OH)
- …and oversight of the operations. Operational activities include clinical review of prior authorization requests and support additional features such as training, ... appeals, and grievances for clients who have delegated UM . + Monitor all activities related to clinical review....+ Working knowledge of utilization management activities such as prior authorization , concurrent review, intake, appeals and… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews ... on prior authorization requests in accordance with national standards, contractual requirements,...preferred. Essential Qualifications * Current licensed LPN or Registered Nurse (RN) with state licensure. Must retain active and… more
- Sanford Health (SD)
- …activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. ... regulations and internal policies that effect resource utilization and potentially, prior authorization . Assists the department in monitoring the utilization… more
- Providence (Beaverton, OR)
- …empower them._** **Providence Health Plan is calling a Manager Utilization Management RN, Prior Authorization who will:** + Be responsible for Management and ... supervision of the PHP Utilization Management ( UM ) or Care Management (CM) clinical programs, outcomes and...training in supervision, management, or leadership + Oregon Registered Nurse License + 3+ years of experience directly managing… more
- Banner Health (AZ)
- …costs. POSITION SUMMARY This position provides oversight of the utilization review, prior authorization and case management staff and activities. This position ... staff and supervisors. CORE FUNCTIONS 1. Leads and manages prior authorization , concurrent review, and case management...recommendations for improvement. 3. Communicates with PA, CM and UM departmental staff and management to ensure that there… more
- US Tech Solutions (May, OK)
- …experience . Registered Nurse in state of residence . Must have prior authorization utilization experience . Able to work in multiple IT platforms/systems ... MANAGED CARE exp and Medicare/Medicaid knowledge. . MUST HAVE UM experience, inpatient utilization management review. . MUST HAVE...knowledge of Milliman/MCG. . MUST HAVE 6 months of Prior Authorization . Education: . Active and unrestricted… more
- US Tech Solutions (RI)
- …experience required. + Must have experience with Medcompass + Must have prior authorization utilization experience. + Managed Care/Medicare experience preferred. ... MANAGED CARE exp and Medicare/Medicaid knowledge. + MUST HAVE UM experience, inpatient utilization management review. + MUST HAVE...knowledge of Milliman/MCG. + MUST HAVE 6 months of Prior Authorization . **Education:** + RN with current… more
- Molina Healthcare (TX)
- …benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina ... **For this position we are seeking a (RN) Registered Nurse with previous experience in Acute Care, Concurrent Review/...+ Processes requests within required timelines. + Refers appropriate prior authorization requests to Medical Directors. +… more
- Fallon Health (Worcester, MA)
- …of purpose** : Under the direction of the Manager of Prior Authorization , communicates with contracted and non-contracted facilities/agencies/providers to ... collect pertinent prior authorization request data and disseminates information...in QNXT as a result of determinations made by Authorization Coordinators, Nurse Reviewers and/or Nurse… more
- YesCare Corp (Bartow, FL)
- … hospital experience with five (5) years corrections experience + Minimum of two (2) years prior experience with UM preferred + Minimum of one (1) year prior ... **Experience & Requirements** + Licensed Registered Professional Nurse currently registered to practice in state of...+ Serves as resource to sites and providers for authorization numbers + Forwards daily inpatient case management abstracts… more
- Billings Clinic (Billings, MT)
- …CM, and department leadership *Conducts UR until all tasks are completed; indicates UM Complete in authorization and/or certification *Communicates with payer UR ... Requirements All new employees must complete several pre-employment requirements prior to starting. Click here (https://billingsclinic.csod.com/ats/careersite/search.aspx?site=15&c=billingsclinic) to learn more!… more
- CDS Life Transitions (Webster, NY)
- …and Experience: + Bachelor's degree in Nursing + State licensure as a Registered Nurse (RN) + Minimum 2 years of prior experience in Utilization Management ... results of these reviews to all involved parties. The UM reviewer will facilitate the timely access to necessary,...within established policy time frames, along with reasons for authorization or denial, supported by objective and unbiased criteria… more
- Centene Corporation (Salem, OR)
- …a fresh perspective on workplace flexibility. **Position Purpose:** Supervises Prior Authorization , Concurrent Review, and/or Retrospective Review Clinical ... communication between utilization management team, members, and providers + Monitors prior authorization , concurrent review, and/or retrospective clinical review… more
- Sanford Health (Sioux Falls, SD)
- …regulations and internal policies that effect resource utilization and potentially, prior authorization . Assists the department in monitoring the utilization ... and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements. May assist with additional… more
- Molina Healthcare (Lexington, KY)
- …benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina ... For this position we are seeking a (RN) Registered Nurse who must be licensed for the state they...+ Processes requests within required timelines. + Refers appropriate prior authorization requests to Medical Directors. +… more
- Elevance Health (Atlanta, GA)
- …Management Representative I** will be responsible for coordinating cases for precertification and prior authorization review. **How you will make an impact:** + ... eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization , and post service requests. + Refers cases… more
