- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes ... regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal… more
- R1 RCM (Boise, ID)
- …platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals Nurse ** , you will help our ... remote, production-driven position. **Here's what you will experience working as a Clinical Appeals Nurse :** + Conduct a detailed review of patient medical… more
- R1 RCM (Boise, ID)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse ** , you will help ... remote production-drive position. **Here's what you will experience working as a Clinical Coding Appeals Nurse :** + Review and interpret medical records to… more
- LA Care Health Plan (Los Angeles, CA)
- …with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los… more
- CareFirst (Baltimore, MD)
- …+ Reviews Clinical Appeals and Grievances documentation written by the clinical appeals nurse and non- clinical supporting team members within ... & Qualifications** **PURPOSE:** The role of the Quality Review Nurse (RN) is to evaluate clinical quality...evaluate clinical quality and procedures within the Clinical Appeals & Grievance Department Government Programs… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, ... safety net required to achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor (RN) directs and coordinates the accurate implementation of the clinical appeal ... and serves as a resource for associates within the Clinical Appeals and Analysis unit supporting Government...School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon… more
- Elevance Health (Los Angeles, CA)
- ** Nurse Appeals - Licensed RN Nurse.../grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting ... our PulsePoint locations. **Shift:** Monday to Friday from 8:00am-5:00pm PST The ** Nurse Appeals ** is responsible for investigating and processing medical… more
- CareFirst (Baltimore, MD)
- …for our membership, and support NCQA accreditation and the Divisional Goals for the Clinical Appeals and Grievance department. We are looking for an experienced ... including (EGWP, DSNP, MAPD). Ensures quality management of the clinical appeal process to reduce the risk of State...goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance… more
- R1 RCM (Chicago, IL)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals and Denials Manager** , you will serve as ... an expert on clinical appeals and denials management. Every day...challenges, and process improvement opportunities. **Required Skills:** + Registered Nurse (active or inactive in good standing and able… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Appeals and Grievances Clinical Operations RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, ... the safety net required to achieve that purpose. Job Summary The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing… more
- CDPHP (Albany, NY)
- …share these values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- Trinity Health (Springfield, MA)
- …Shift **Description:** Requires BSN At **Mercy Medical Center** the **Utilization Review/ Appeals & Denials** **RN** performs utilization review with payers, assists ... care determinations using screening criteria, and assists the physician, bedside Registered Nurse , ICC and Social Worker with utilization management and clinical … more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...health plan. Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California, Active BLS -… more
- VNS Health (Manhattan, NY)
- …Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + ... Health Plans is seeking a dedicated Manager, Grievance and Appeals (RN)to lead the daily operations of our grievance...quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or… more
- MetroHealth (Cleveland, OH)
- …departments and more than 20 health centers.** **Summary:** **Performs secondary clinical chart reviews, resolves DRG discrepancies, and educates clinical ... opportunities to improve documentation accuracy. Reviews DRG downgrades and strategic CDI appeals , and responds to payor audits and inpatient downgrade requests when… more
- University of Virginia (Haymarket, VA)
- …minimum loss of revenue and maximum payment for services. Utilizing persuasive clinical arguments and tenacious communication skills, both oral and written, creates ... problem solving methodology to discern trends in payor behaviors and/or our clinical documentation/practice that need to be communicated back to departments or… more
- MetroHealth (Cleveland, OH)
- …appropriate and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the appropriateness of ... the MHS.** Qualifications: Bachelor's degree in nursing. Current Registered Nurse License State of Ohio. Minimum of 5 years... License State of Ohio. Minimum of 5 years clinical experience. Knowledge and experience with medical necessity criteria… more
- Scripps Health (San Diego, CA)
- …for over 10 years. We invite you to join our Revenue Cycle team as a Registered Nurse of Appeals . * In this role, you will be responsible for the following * ... and system reimbursement. * Responsible for completing government and commercial appeals for systemwide hospital billing. * Understands basic denial rationales and… more
- Select Medical (Los Angeles, CA)
- …Century City / Los Angeles, CA Case Manager (CM) - Full Time (on-site) Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) **Pay Rate: $50 - $58.65 ... process. The primary job functions in Case Management include: Clinical Interventions/Discharge and Care Planning Management; Fiscal Management; and Payer/Referral… more
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