- CareFirst (Cumberland, MD)
- … claims processing and/or adjudication. The incumbent will handle pre and post claim medical review for Commercial, FEP and Medicare Advantage Plans. ... of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to… more
- Bristol Myers Squibb (Madison, NJ)
- …in accordance with relevant guidelines. + Ability to demonstrate leadership within the medical review team to help drive best practices aligned with strategic ... + Determine acceptability of data/references used to support promotional claims and provide expert guidance as well as effective...or the pharmaceutical industry. + Demonstrates thorough understanding of medical writing and medical review … more
- Rising Medical Solutions (Chicago, IL)
- …With offices, providers, and case managers nationwide, RISING provides comprehensive medical claims solutions to our valued clients: insurance carriers, ... experience in acute care, surgery and/or orthopedic + Workers' Compensation medical bill review experience a major plus + Understanding of CPT and ICD-10… more
- ConvaTec (South Easton, MA)
- …guideline requirements needed to set up and maintain client accounts of 180 Medical . + Review received documentation to determine insurance requirements are met. ... records within Medtrack, an internal database, to support client services and claim payment processes. + Support Team Supervisor on miscellaneous projects + Must… more
- Takeda Pharmaceuticals (Lexington, MA)
- …to the best of my knowledge. **Job Description** **Senior Manager, US Medical Ad/Promo Regulatory Review ** **Takeda Pharmaceutical** **Lexington, MA or Exton, ... the role:** Join Takeda as a Senior Manager, US Medical Ad/Promo Regulatory Review where you will...comments and any other interactions regarding use of promotional claims for assigned products. + Ensure review … more
- The Arora Group (Bethesda, MD)
- …providers in gathering clinical information and may also provide education on the medical review process. + The Contractor performing as the License Practical ... Licensed Practical Nurse (LPN) - Utilization Review Nurse Currently recruiting a Licensed Practical Nurse...and validity of the item(s) supplied in a valid claim through the use of medical policy… more
- US Tech Solutions (Columbia, SC)
- …Utilizes available resources to promote quality, cost effective outcomes. Performs medical or behavioral review /authorization process. Ensures coverage for ... healthcare needs of our members. **Responsibilities:** + Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying… more
- City of New York (New York, NY)
- …appropriate, negotiate and settle claims within delegated monetary authority level; 8) Review medical providers and law firms to ensure all entities are in ... not limited to: 1) Manage individual No-fault files and review investigation reports, medical reports, bills and...to gather information relevant to the investigation of the claim ; 11) Investigate, identify, and report fraudulent claims… more
- Select Medical (Mechanicsburg, PA)
- …workers' compensation and work-related injury claims filed, manage and monitor claim activity to mitigate liability on future medical and indemnity costs, ... & EID Leave, 401K company match & more** Select Medical is seeking an Employee Safety and Claim...Claim coordinator and reserve monitoring: continually monitor and review reserves on all… more
- Travelers Insurance Company (Lake Oswego, OR)
- …This position is responsible for handling Personal and Business Insurance First Party Medical claims from the first notice of loss through resolution/settlement ... you do and where you do it. **Job Category** Claim **Compensation Overview** The annual base salary range provided...Proactively manages the process to ensure proper payment, (ie review medical bills and medical … more
- New York State Civil Service (Albany, NY)
- …incumbent will provide supervision to claims review staff within the Pended Claims Unit of the Bureau of Medical Review . Duties include providing ... of Medical and Dental Directors, Bureau of Medical Review One Commerce Plaza City Albany...pended for timely filing, requests for two-year waiver for claims processing, high-cost outlier claims review… more
- Humana (Columbus, OH)
- …will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to ... clinical group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed… more
- Medical Mutual of Ohio (OH)
- …the continuum of care. **Responsibilities** + Independently evaluates basic to complex medical claims and/or appeal cases and associated records by applying ... stay and level of care + Extrapolates and summarizes medical information for physician review or other...terminology and managed care processes + Familiarity with clinical claim management including ICD 10, CPT, HCPC, and revenue… more
- The County of Los Angeles (Los Angeles, CA)
- …direction, administrative and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General Medical Center, one of ... for and the effective conduct of the system to review patients' medical charts to ascertain the...complete this questionnaire completely and correctly. The experience you claim in this supplemental questionnaire must be consistent with… more
- Providence (NM)
- …we must empower them.** **Providence is calling a Sr. Professional Liability Medical Claims Manager who will:** **Investigate, Evaluate, and Manage Professional, ... Program:** + Communicate with patients, claimants, caregivers, providers, leadership + Review and analyze medical records, interview witnesses, assist with… more
- Centene Corporation (New York, NY)
- …management, cost containment, and medical quality improvement activities. + Performs medical review activities pertaining to utilization review , quality ... medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. + Supports effective implementation… more
- US Tech Solutions (Columbia, SC)
- …following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge ... indicated protocol sets or clinical guidelines. Provides support and review of medical claims and...families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each… more
- Sharp HealthCare (San Diego, CA)
- …and outcomes studies as directed by the Quality Management + Committee, Peer Review Committee and Chief Medical Officer and reports findings in conjunction ... Director. + Assists in POS/PPO Case Management and high-cost review with CMO and Claims management teams....+ Able to manage difficult peer situations arising from medical care review . + Appreciation of cultural… more
- Mount Sinai Health System (New York, NY)
- …practices; routes requests to medical leadership when appropriate + Documents authorization review for medical and pharmacy claims . + Prepares case ... related documents required to modify and/or add necessary services. + Performs continuing review of medical records; analyzing data trends and implementing best… more
- Kohler Co. (Kohler, WI)
- …for evaluating and authorizing (or denying) associate short-term and long-term disability claims , Family Medical Leaves and other Kohler Co. Paid Leaves. ... Claim or Leave is approved, the Sr. Disability Claims Examiner then updates internal documentation and systems, coordinates...to functional job requirements for work accommodation. + Facilitate medical case review with clinical experts when… more
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