- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** We are looking for a Director, Medical Review & Appeals for our Government Programs lines of business. The incumbent ... the required work experience. **Licenses/Certifications Upon Hire Required:** + RN - Registered Nurse -...or health insurance environment with a focus on Clinical Medical Review and Appeals and… more
- St. Luke's University Health Network (Allentown, PA)
- …ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all ... Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required, BSN preferred. Current license required. .… more
- CareFirst (Baltimore, MD)
- …experience is required in addition to the required work experience. **Licenses/Certifications:** + RN - Registered Nurse - State Licensure And/or Compact ... with dynamic goals resulting in the full and fair review of appeals and designed to achieve...and utilization management, and systems software used in processing appeals . + Knowledge and understanding of medical … more
- University of Washington (Seattle, WA)
- …payer decisions in a timely manner + Review clinical denials and initiate appeals process + Conduct medical necessity reviews, based on denial root cause, ... clinical denials to determine next steps. Additionally, they conduct appeals as appropriate by reviewing medical necessity,...cycle **REQUIREMENTS** + Active licensure to practice as a Registered Nurse in Washington State + Bachelor's… more
- Elevance Health (Indianapolis, IN)
- …preferred. + 3 years of clinical experience as a Registered Nurse is strongly preferred. + Experience reviewing medical records, investigation, and/or ... ** Nurse Appeals ** **Location: Indiana** **Virtual:** This...and forwards to Medical Director for final review and decision. + Ensures that appeals … more
- CVS Health (Columbus, OH)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... will be responsible for processing the medical necessity of Medicare appeals for participating...and typing on the computer. + Responsible for the review and resolution of clinical appeals . +… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse ( RN ) Manager, Appeals and Grievances General Operations (Clinical) Job Category: Clinical Department: CSC Appeals & Grievances ... + Excellent verbal, written communication and presentation skills. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and… more
- Nuvance Health (Danbury, CT)
- …in nursing, health administration, or a related field preferred * Current licensure as a registered nurse ( RN ) * Minimum of 5 years of clinical experience ... leadership and operational oversight for a team of utilization review staff, denials and appeals specialists, non-clinical...medical necessity outreach, and feedback to the utilization review team on denial outcomes. * *Discharge Planning &… more
- State of Colorado (Denver, CO)
- …(HP III RN ) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5183355) Apply Registered Nurse , Health Compliance Inspector Home Care - ... a measurable difference in the health, safety, and well-being of Colorado communities. As a Registered Nurse ( RN ) Health Professional III , you will use your… more
- LA Care Health Plan (Los Angeles, CA)
- …the ability to manage multiple training initiatives simultaneously. Licenses/Certifications Required Licensed Registered Nurse ( RN ) - Active, current and ... Lead Customer Solution Center Appeals and Grievances RN Job Category:...clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for… more
- Molina Healthcare (WI)
- JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for internal appeals clinical processes - ensuring that appeals ... licensure, Diagnosis-Related Group (DRG) experience, 2 years of Utilization Review and/or Medical Claims Review ...or equivalent combination of relevant education and experience. * Registered Nurse ( RN ). License must… more
- State of Colorado (Golden, CO)
- Registered Nurse I, RN I - Campus at Lookout Mountain, Youth Services Center - Golden Print ... (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5185059) Apply Registered Nurse I, RN I...practice. Obtains laboratory and other diagnostic procedures ordered by medical providers, review results and notify provider… more
- Rochester Regional Health (Rochester, NY)
- …BLS - Basic Life Support - American Heart Association (AHA)American Heart Association (AHA), RN - Registered Nurse - New York State Education Department ... Job Title: Registered Nurse I Department: Utilization Management...40 hours (Full-Time) Schedule: Monday - Friday, Days SUMMARY: Review all inpatient medical necessity denials for… more
- Molina Healthcare (Tacoma, WA)
- For this position we are seeking a ( RN ) Registered Nurse who...Looking for a RN with experience with appeals , claims review , and medical ... authorization, managed care, or equivalent combination of relevant education and experience. * Registered Nurse ( RN ). License must be active and unrestricted… more
- Nuvance Health (Danbury, CT)
- …percentage of charge reimbursement payers. * If concurrent inpatient case does not meet medical necessity review criteria during the first level review , ... *Description* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12-24 hours… more
- State of Colorado (CO)
- CDOC Registered Nurse ( Nurse I) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5123731) Apply CDOC Registered Nurse ( Nurse ... and staff instruction; + Assists physicians, physician assistants, and nurse practitioners with minor medical and surgical...Applicant must possess a current, valid license as a Registered Nurse from the Colorado Board of… more
- BronxCare Health System (Bronx, NY)
- …response by the department physician advisors and clinical staff. Qualifications - NYS Registered Nurse required - The Appeal Manager must have excellent verbal ... Overview The Appeals Manager is responsible to assist in the...Medical Audit Contractors, and other licensing, accrediting, or review agencies. -Provides regular and special reports, in writing… more
- Sacramento County (Sacramento, CA)
- Supervising Registered Nurse D/CF Print (https://www.governmentjobs.com/careers/sacramento/jobs/newprint/448883) Apply Supervising Registered Nurse ... 5:00 pm on: 12/1/25, 2/2/26, 4/6/26, 6/1/26, 8/3/26, 10/5/26, 12/7/26 Supervising Registered Nurse - Detention/Correctional Facility is the first level… more
- Sacramento County (Sacramento, CA)
- …read and understood the above instructions. 02 Select the one box that best describes your Registered Nurse ( RN ) license issued by the State of California. + ... Registered Nurse D/CF (Level I/II) Print...interviewing patients and assisting them in follow-up care; maintaining medical and medication supplies; rendering emergency medical … more
- CareFirst (Baltimore, MD)
- …complications. **QUALIFICATIONS:** **Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse - State Licensure ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis,...in a healthcare payor organization. 2 years' experience in Medical Review , Utilization Management or Case Management… more