- Martin's Point Health Care (Portland, ME)
- …reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as ... "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as...internal guidelines for medical necessity reviews. + Manage the review of medical claims disputes, records, and… more
- The County of Los Angeles (Los Angeles, CA)
- UTILIZATION REVIEW NURSE SUPERVISOR II Print (https://www.governmentjobs.com/careers/lacounty/jobs/newprint/2784979) Apply UTILIZATION REVIEW ... and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General...REQUIRED: A current license to practice as a Registered Nurse issued by the California Board of Registered Nursing.… more
- Intermountain Health (Murray, UT)
- …etc.) + Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic ... discharge planning efforts, coordination of transition of care and manage utilization through appropriate review of authorization requests. Job Essentials… more
- Travelers Insurance Company (Buffalo, NY)
- …**What Is the Opportunity?** This position is responsible for conducting in-house utilization review with emphasis on determining medical necessity for ... do and where you do it. **Job Category** Claim, Nurse - Medical Case Manager **Compensation Overview** The annual...to the compensable injury and for adhering to multi-jurisdictional Utilization Review criteria. **What Will You Do?**… more
- The Cigna Group (Bloomfield, CT)
- …addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of ... include, but not limited to:** + Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C + Ability to differentiate… more
- CVS Health (Jefferson City, MO)
- …operation. Work schedules may include weekends and holidays and evening rotations._ As a Utilization Management Nurse Consultant you will be responsible for the ... line with regulatory and accreditation requirements for member and/or provider claims . Independently coordinates the clinical resolution with clinician/MD support as… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Nurse Specialist RN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: ... net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates,...on case reviews for pre-service, concurrent, post-service and retrospective claims medical review . Monitors and oversees the… more
- CVS Health (Charleston, WV)
- …include weekends and holidays and evening rotations._ This is a fully remote Utilization Management Nurse Consultant opportunity. The schedule is Monday through ... EST time zone where the candidate resides. **.** Responsible for the review and evaluation of clinical information and documentation related to outpatient therapy… more
- Elevance Health (Tampa, FL)
- …managed care industry strongly preferred. + 2 years of experience in In-Patient, utilization review / management, evaluating medical necessity for services and ... RN Utilization Management Nurse Sr. (Medicaid-InPatient) JR130851...medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.… more
- CVS Health (High Point, NC)
- …3 months. Following training, position is remote with occasional in office requirement.** Utilization Review - Precertification Nurse is responsible for ... innovators. **Fundamentals:** Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit plan eligibility… more
- Mount Sinai Health System (New York, NY)
- **Job Description** The Utilization Review Manager for the Selikoff Centers for Occupational Health is responsible for the management of program operations ... records, and internal and external regulatory and survey requirements. + The Utilization Review Manager collaborates with multiple professionals to support and… more
- CareFirst (Baltimore, MD)
- …detail can be shared during the interview process. Plans, organizes, and manages utilization review programs. Directs the utilization of referral services. ... Upon Hire Required. **Experience:** 8 years' Experience in a clinical and utilization review role. 3 years Management experience. **Preferred Qualifications:** +… more
- Prime Healthcare (Ontario, CA)
- …Clinical Utilization Management (UM) provides comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans, according ... needs. + Provides strategic leadership, development, and supervision to utilization review department, provides interprofessional collaboration with… more
- Molina Healthcare (Lexington, KY)
- …SKILLS & ABILITIES:** + Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two ... years of experience in Claims Auditing, Medical Necessity Review and Coding experience + Familiar with state/federal regulations **REQUIRED LICENSE,… more
- Elevance Health (Columbus, OH)
- …prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the identification ... ** Utilization Management Representative I** **Location** : This is...responsible for coordinating cases for precertification and prior authorization review . **How you will make an impact :** +… more
- Elevance Health (Topeka, KS)
- …prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the identification ... ** Utilization Management Rep I** **Location:** This position will...responsible for coordinating cases for precertification and prior authorization review . **How you will make an impact:** + Managing… more
- Elevance Health (Tallahassee, FL)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. + ... ** Utilization Management Representative II** **Location:** Must live within...impact:** + Managing incoming calls or incoming post services claims work. + Determines contract and benefit eligibility; provides… more
- UCLA Health (Los Angeles, CA)
- …Case Management + Work directly with a nurse team lead + Review pending claims for approval or denial Salary Range: $34.37- $47.31/hourlyQualifications We're ... more at UCLA Health. Under the direction of the Utilization Management, Assistant Manager, you will play a key...and prepare necessary documents for the next level of review + Maintain and prepare specific reports and manage… more
- Rising Medical Solutions (Chicago, IL)
- …was born - and continues to thrive. Rising Medical Solutions is looking for a Nurse Auditor who wants to make their mark in the world of medical cost containment. ... team and maximize client savings by reviewing medical bills from a nurse perspective, including appropriate billing, coding and treatment, fee schedule compliance,… more
- BronxCare Health System (Bronx, NY)
- …collection, analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality Improvement ... prepare a response for submission in appeal. - In absence of Director, will review denial correspondence to determine validity of denial reason and course of action… more