- Harbor Health Services, Inc. (Mattapan, MA)
- … cases and those upon request of utilization or finance department. Works with UM RNs and Senior Medical Director to deny claims when appropriate. ... of care within a managed care environment. Additionally, the Director of UM ensures that collaborative relationships... Medical Director to resolve complex medical review issues and utilization cases requiring… more
- Spectraforce Technologies (Columbia, SC)
- …back up review determinations. Identifies and makes referrals to appropriate staff ( Medical Director , Case Manager, Preventive Services, Subrogation, Quality of ... Role Name: Managed Care Coordinator UM II Location: Columbia, SC 29203 Work Environment:...conversion Job Summary: Duties/About the role: Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …staff on managed care and Medicaid policies and procedures D. Conducts staff and medical director audits on appeal activities + Assists with appeal file ... **Overview** BroadPath is seeking a highly motivated and results-driven ** UM RN Appeals Coordinator.** This role collaborates with clinical review staff, medical … more
- Alameda Health System (Oakland, CA)
- …paid time off plans Role Overview: Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational ... utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures. Analyze data and generate reports… more
- Universal Health Services, Inc. (Sherman, TX)
- …US States, Washington, DC, Puerto Rico and the United Kingdom. www.uhs.com The UM Supervisor oversees the utilization management of the Behavioral Health Center ... Responsibilities Texoma Medical Center, a 414-bed acute care facility has...with the CBO as needed. This position oversees the Utilization Management Coordinator. The UM Supervisor reports… more
- Santa Clara Family Health Plan (San Jose, CA)
- …the guidance and direction of the UM department RN Manager or Director , the Utilization Management Review Nurse (LVN) performs prospective and retrospective ... Utilization Management Review Nurse LVN Salary Range: $74,557...Utilization Management and/or Case Management. (R) Knowledge of MediCal and/or Medicare guidelines and regulations. (D) Knowledge of… more
- San Francisco Health Plan (San Francisco, CA)
- …clinical and operational leadership to the Prior Authorizations (PA) team within the Utilization Management ( UM ) function. You will manage a team of registered ... Reporting to the Director of Clinical Operations, the Nurse Manager, Prior...MCG, SFHP policies, Medi-Cal and Medicare guidelines). Collaborate with UM leadership and Medical Directors to design… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …HHSC Intake Portal - Texas Integrated Eligibility Redesign System (TIERS) + Supports the Medical Director throughout the EMR and State Fair Hearing process + ... with UM Prior Authorizations, Appeals, Fair Hearings and External Medical Review + Community Health Worker (CHW) certification, Texas Department of State… more
- Universal Health Services, Inc. (Newark, DE)
- …Abuse Services | Rockford Center | Newark, DE Position Summary: The PRN Utilization Management ( UM ) Coordinator plays a critical role in ensuring appropriate ... within a behavioral health setting. This position is responsible for conducting utilization reviews, verifying medical necessity, and coordinating with clinical… more
- Central California Alliance for Health (Merced, CA)
- …and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss ... A member complaint involving an adverse benefit determination by an Alliance Utilization Management ( UM ) decision. Member Grievances (Complaints) : An oral… more
- Santa Clara Family Health Plan (San Jose, CA)
- …for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review. Assist ... TEMPORARY POSITION FLSA Status: Non-Exempt Department: Health Services Reports To: Director , Behavioral Health GENERAL DESCRIPTION OF POSITION The Behavioral Health… more
- Katmai (Usaf Academy, CO)
- …with military and civilian healthcare providers and staff and uses Utilization Management ( UM ) systems support to identify high-risk/high-cost patients ... and provides upon request. + Reports monthly summary of care to Director , Medical Management (MM) or designee. + Conducts monthly evaluation, in conjunction with… more
- CVS Health (Springfield, IL)
- …Account Management in support of Key Clients as assigned. The Medical Director transacts Utilization Management UM activities (prior authorization and ... Fortune 6 company, has an outstanding opportunity for a Medical Director - Medical Affairs...review activities and other quality oversight processes for internal Director UM decisions. If specifically assigned to… more
- Dignity Health (Bakersfield, CA)
- …the managed care populations. This leader will have direct oversight of the Medical Director of Utilization Management ( UM ) and the Medical ... as providing clinical leadership and guidance to other physician medical directors within the UM department, ensuring...and Clinical Oversight functions. + Oversee and manage the medical director capacity to support Managed Care… more
- Centene Corporation (Jefferson City, MO)
- …hearings, STARS metrics + Previous experience with ensuring high quality medical director training to review Medicare UM and appeals, Clinical review quality ... fresh perspective on workplace flexibility. **Position Purpose:** Lead a team of medical directors and supervise MD's responsible for utilization management and… more
- Humana (Little Rock, AR)
- … Director , depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members ... caring community and help us put health first** The Medical Director relies on medical ...insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management… more
- CenterWell (Boston, MA)
- …**Additional Information** Will report to the Director of Physician Strategy at Utilization Management. The Medical Director conducts Utilization ... a part of our caring community and help us put health first** The Medical Director , Primary Care relies on medical background and reviews health claims. The… more
- Humana (Jefferson City, MO)
- …Become a part of our caring community and help us put health first The Medical Director actively uses their medical background, experience, and judgement to ... to operationalize this knowledge in their daily work. The Medical Director 's work includes reviewing of all...Delivery Systems, health insurance, or other healthcare providers. + Utilization management experience in a medical management… more
- Integra Partners (Troy, MI)
- …+ Provide day-to-day clinical leadership and oversight to the Utilization Review Medical Director (s) and clinical UM team. + Ensure consistent, accurate, ... require. The Senior MD provides clinical oversight to the Utilization Review Medical Director (s), ensures...+ Experience as a health plan medical director + Experience with DMEPOS UM programs,… more
- Integra Partners (Troy, MI)
- The Utilization Review Medical Director is responsible for conducting clinical reviews of Durable Medical Equipment (DME) and related requests to support ... Integra's Utilization Management ( UM ) operations. This full-time, salaried...committed to consistency, compliance, and evidence-based decision making. The Utilization Review Medical Director 's… more
