- R1 RCM (Salt Lake City, UT)
- …**Here's what you will experience working as a Clinical Appeals Nurse :** + Conduct a detailed review of patient medical records and payer denial ... analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals Nurse ** , you...contractors or commercial payers. Every day you will thoroughly review patient clinical and hospital course documentation,… more
- Molina Healthcare (Georgetown, KY)
- …for appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making...specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service… more
- R1 RCM (Chicago, IL)
- …automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse ** , you will help review and interpret medical records to draft ... position. **Here's what you will experience working as a Clinical Coding Appeals Nurse :** + Review and interpret medical records to appeal denied and… more
- HCA Healthcare (Nashville, TN)
- …HCA Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Clinical Reviewer with Parallon you can be a part of an organization ... in our organization. We are looking for an enthusiastic Clinical Reviewer to help us reach our...goals. Unlock your potential! **Job Summary and Qualifications** The Clinical Review Specialist is responsible for performing… more
- Centene Corporation (Austin, TX)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... a candidate who resides in Texas. **Position Purpose:** Performs clinical reviews needed to resolve and process appeals...analyzing the basis for the appeal + Ensures timely review , processing, and response to appeal in accordance with… 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
- US Tech Solutions (Columbia, SC)
- …services, and appeals . Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and ... I would love to have someone with prior insurance/utilization review experience, but I know that is not very...individual patient's benefits contract and our medical policies. The nurse would read through clinical information, ensuring… more
- Elevance Health (Rancho Cordova, CA)
- ** Nurse Appeals - Licensed RN Nurse ** **Location:** This position will work in a hybrid model (remote and office). Ideal candidates will live in the state of ... **Shift:** Monday to Friday from 8:00-5:00 pm PT The ** Nurse Appeals ** is responsible for investigating and...medical information for medical director, consultants and other external review . + Prepares recommendations to either uphold or deny… more
- Elevance Health (Los Angeles, CA)
- ** Nurse Appeals - California candidates only** **Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health ... Tuesday - Saturday 9:00am to 5:30 pm PST.** The ** Nurse Appeals ** is responsible for investigating and...medical information for medical director, consultants and other external review . + Prepares recommendations to either uphold or deny… more
- CareFirst (Baltimore, MD)
- …programs/plans (all benefits/incentives are subject to eligibility requirements). **Department** Clinical Appeals and Analysis **Equal Employment Opportunity** ... all lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State...with dynamic goals resulting in the full and fair review of appeals and designed to achieve… more
- HCA Healthcare (Nashville, TN)
- …our HCA Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Clinical Appeals Team Lead with Parallon you can be a part of an ... in our organization. We are looking for an enthusiastic Clinical Appeals Team Lead to help us...Unlock your potential! **Job Summary and Qualifications** The Compliance Nurse Team Lead is responsible for providing clinical… more
- CDPHP (Albany, NY)
- …requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render ... you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering...will be responsible for tracking, trending and monitoring of appeals , grievances, NYS external review , and making… more
- Genesis Healthcare (Philadelphia, PA)
- …Assists the denial management team by conducting a comprehensive analytical review of patient's medical records. Appeal Writer/ Reimbursement Analyst will write ... to be paid. RESPONSIBILITIES/ACCOUNTABILITIES: Reviews patient medical records; utilize clinical , regulatory knowledge and skills to provide convincing appeal… more
- St. Mary's Healthcare (Amsterdam, NY)
- …based on experience and other factors permitted by law. Responsibilities: * Uses clinical and coding knowledge to ensure accurate and compliant charge items and to ... and audit requests and coordinates attempts to overturn denials by drafting appeals , negotiating with payers, or following up with payer utilization review… more
- VNS Health (Manhattan, NY)
- …You Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. ... to day activities for staff handling of grievances and appeals for one of the following VNS Health Plans...quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of… more
- Carle (Urbana, IL)
- …reviews where medical necessity is being challenged. Responsible for enterprise wide outpatient clinical review and appeals on Medicare and Medicaid RAC, ... Weekend Requirements: no + Other Posting Information: Registered Professional Nurse (RN) License Illinois upon hire. + Holiday Requirements:...flow to ensure best practice. + Responsible for the clinical review and appeals for… more
- Molina Healthcare (Florence, KY)
- …compliance with all state and federal regulations and guidelines. + Analyzes clinical service requests from members or providers against evidence based clinical ... in consistent and efficient manner. + Makes appropriate referrals to other clinical programs. + Collaborates with multidisciplinary teams to promote Molina Care… more
- Molina Healthcare (Bowling Green, KY)
- …identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience + Documents clinical review summaries, bill ... **JOB DESCRIPTION** **Job Summary** Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …It encompasses a member and provider call center, provider correspondence and appeals , clinical review , member correspondence and reconsiderations, ... Summary: The RN Clinical Provider Post Service Review Manager , led by a Registered Nurse...associates who research and respond to provider inquires and appeals , build cases, and perform claim adjustments in a… more
- State of Colorado (Denver, CO)
- …DYS + Guide and support clinic operations + Respond to case escalations + Provide clinical coverage as needed + Review and approve the ordering of supplies + ... provides support for performance evaluations. This role also includes review and implementation of preventive health care services, program,...How many years of experience do you have as Nurse Manager, or Clinical Supervisor? + 2… more