• Customer Solution Center Appeals

    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...of resolution letters. Reviews grievance cases that require immediate clinical quality of care, initial coding of… more
    LA Care Health Plan (11/04/24)
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  • Appeals Nurse Consultant (Remote)

    CVS Health (Hartford, CT)
    …zone of residence. **Position Summary** Responsible for the review and resolution of clinical appeals . Reviews documentation and interprets data obtained from ... support as required. This position may support UM, MPO, Coding , or Behavioral Health appeals . **Required Qualifications**...RN licensure in state of residence + 3+ years clinical experience **Preferred Qualifications** + Appeals Experience… more
    CVS Health (11/03/24)
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  • Clinical Appeals Specialist

    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
    CDPHP (10/26/24)
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  • Outpatient Denial/ Appeals Specialist- RN

    Carle (Urbana, IL)
    …resource in outpatient clinical documentation review to establish and manage clinical and prior authorization denial appeals for the Carle enterprise. ... Represents Carle in clinical meetings and writing appeals on outpatient accounts where medical necessity, level of care or prior authorization is questioned.… more
    Carle (08/23/24)
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  • Appeals Audit Specialist - McLaren Careers

    McLaren Health Care (Bay City, MI)
    …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... + Certified Medical Coder, Certified in Healthcare Compliance, Certified Coding Specialist, or Certified Clinical Documentation Specialist certifications more
    McLaren Health Care (09/26/24)
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  • Coding Verifier

    Sanford Health (SD)
    …- $33.00 **Job Summary** Based on location and depending upon role, the Coding Verifier may perform the following tasks, but not limited to, working collaboratively ... released into current procedural terminology (CPT), healthcare common procedure coding system (HCPCS), and international classification of diseases (ICD-10) codes… more
    Sanford Health (09/26/24)
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  • Nurse - Surgical Provider Appeal Analyst…

    Travelers Insurance Company (Tampa, FL)
    …provided. + Compare bill and rates with appropriate fee schedule rules, clinical edits, and Medicare, National Correct Coding Initiative (NCCI), internal ... a plus. **What is a Must Have?** + Registered Nurse or Licensed Practical Nurse with Surgical clinical experience. **What Is in It for You?** + **Health… more
    Travelers Insurance Company (11/01/24)
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  • Revenue Integrity Nurse Auditor

    Childrens Hospital of The King's Daughters (Chesapeake, VA)
    …defense, LifeNet and special focus audits and reports findings. + Serves as a clinical resource for coding / denial management and customer service issues. + ... + GENERAL SUMMARY + The Revenue Integrity Nurse Auditor is responsible for the auditing and...supporting documentation, as well as facilitates the completion of appeals in a timely manner. + Prepares trend and… more
    Childrens Hospital of The King's Daughters (10/26/24)
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  • RN Clinical Provider Post Service Review…

    Blue Cross Blue Shield of Massachusetts (Hingham, MA)
    …encompasses a member and provider call center, provider correspondence and appeals , clinical review, member correspondence and reconsiderations, enrollment, ... clinical (RN) reviewers and offers guidance on clinical and coding integrity reviews that are...required. Bachelor's degree preferred + Experience with the Provider appeals process required; coding and claims knowledge… more
    Blue Cross Blue Shield of Massachusetts (10/23/24)
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  • Registered Nurse Assessment Coordinator…

    Wesley Enhanced Living (Philadelphia, PA)
    …as a Best Workplace in our industry! Hiring Immediately! The Registered Nurse Assessment Coordinator (RNAC) provides for the initial assessment and periodic ... implement and update resident Plan of Care. The Registered Nurse Assessment Coordinator (RNAC) would: + Ensure accuracy of...accuracy of all sections of Multiple Data Set (MDS) coding to maximize company reimbursement consistent with the levels… more
    Wesley Enhanced Living (10/01/24)
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  • Clinical Documentation Improvement…

    Adecco US, Inc. (Phoenix, AZ)
    …accounts for clinical validation and works with the denials team for appeals . + Monitor clinical quality measures for timely processing ie PSIs, HACs ... Certification as Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Professional (CDIP) + Coding certification… more
    Adecco US, Inc. (10/30/24)
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  • Utilization Management RN (Relief) - Case…

    Stanford Health Care (Palo Alto, CA)
    …medical necessity. + Stay current with regulatory policies and guidelines related to clinical appeals . + Apply regulatory knowledge to strengthen appeal cases. + ... Stanford Health Care job.** **A Brief Overview** The Utilization Management Registered Nurse (UM RN) will be responsible for ensuring the efficient and effective… more
    Stanford Health Care (10/23/24)
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  • AVP Care Coordination

    Nuvance Health (Danbury, CT)
    …and operational oversight for a team of utilization review staff, denials and appeals specialists, non- clinical support staff while partnering with local case ... appeals specialists to meticulously investigate denied claims, prepare comprehensive appeals , and collaborate with clinical staff to ensure successful… more
    Nuvance Health (10/26/24)
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  • Medical Coder Sr. Account Manager

    TEKsystems (Raleigh, NC)
    …to be considered Description: * Account Manager serves as the member of the Corporate Coding Team by reviewing denials and appeals for coding related issues ... setting and hospital billing highly preferred. Additional Skills & Qualifications: * 5 Years Coding - Inpatient OR 5 Years Clinical - Related Area And… more
    TEKsystems (10/24/24)
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  • RN-Utilization Management

    ERP International (Nellis AFB, NV)
    …admissions, including all eligible beneficiaries, to civilian hospitals and notifies Clinical Nurse Case Manager and Patient Administration Element as ... **Overview** ERP International is seeking **Registered Nurse (RN) Utilization Managers** for full-time positions in support of theMike O'Callaghan Military Medical… more
    ERP International (11/02/24)
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  • Utilization Management Specialist NE

    Cleveland Clinic (Vero Beach, FL)
    …information to the payer, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and ... information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and… more
    Cleveland Clinic (10/31/24)
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  • Reviewer I, Medical

    ManpowerGroup (Columbia, SC)
    …OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social ... of professional, inpatient or outpatient, facility benefits or services, and addressing appeals . Your role will involve documenting decisions in line with … more
    ManpowerGroup (09/21/24)
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  • Director-Utilization and Denials Management

    WellSpan Health (York, PA)
    …Works with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation for review as well as coding activities and DRG ... implementation of new strategies to continue to improve operations and clinical services. Collaborates with interdisciplinary teams, such as Insurance Specialty… more
    WellSpan Health (10/08/24)
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  • RN Utilization Manager - Medicine, Oncology,…

    UNC Health Care (Chapel Hill, NC)
    …with Medical Surgical and/or Psychiatry bedside experience. The team: + Completes clinical reviews for all areas: Inpatient, Observation, Extended Recovery + Ensures ... hospital revenue by working with payors for insurance authorizations, denials, and appeals + 40 hrs/week with flexible schedule options available + Weekend rotation… more
    UNC Health Care (10/26/24)
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  • Utilization Management Director (Hybrid)

    CareFirst (Baltimore, MD)
    …authorization of services and approved claims. + Oversees retrospective reviews, case appeals , billing coordination, and clinical support. + Ensure that staff ... **Resp & Qualifications** **PURPOSE:** We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work… more
    CareFirst (08/27/24)
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