- Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)
- …responsible for completing the Medical Policy activities outlined in BCBSLA's Medicare Advantage Medical Policy Development Policies & Procedures locating, tracking ... heavy workloads accurately. **Licenses and Certifications** + Health Services\RN - Registered Nurse - State Licensure And/or Compact State Licensure to practice in… more
- Molina Healthcare (Long Beach, CA)
- …the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the ... medical director, and quality improvement staff. + Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews quality referred… more
- The Cigna Group (Nashville, TN)
- The Nurse will: + Deliver professional activities in the Case Management job family. + Coordinate enrollee care needs across the continuum for assigned members who ... areas. + Provide standard professional advice and creates initial reports/analyses for review . + Provide guidance, coaching, and direction to more junior members of… more
- The Cigna Group (Bloomfield, CT)
- …effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and ... Medical Directors when services do not meet criteria or require additional review . + Participation in staff meetings, regular trainings and other collaborative… more
- State of Connecticut, Department of Administrative Services (Middletown, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 240830-5613FP-001 Location Middletown, CT Date Opened 9/5/2024 12:00:00 AM Salary ... - is accepting applications for one (1) full-time Utilization Review Nurse Coordinator (https://www.jobapscloud.com/CT/specs/classspecdisplay.asp?ClassNumber=5613FP&R1=&R3=) position, in Middletown,… more
- InnovaCare (San Juan, PR)
- …to the business. MMM Holdings, Inc.Job Description Inpatient Unit POSITION: Concurrent Review Nurse (CRN) POSITION DESCRIPTION Manages the inpatient utilization ... visits to Acute, SNF, and Rehabilitation Inpatient facilities to concurrently review admissions and continued stay to determine appropriate Utilization, Quality… more
- The County of Los Angeles (Los Angeles, CA)
- UTILIZATION REVIEW NURSE SUPERVISOR II Print (https://www.governmentjobs.com/careers/lacounty/jobs/newprint/2784979) Apply UTILIZATION REVIEW NURSE ... administrative and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General Medical Center, one of the largest… more
- US Tech Solutions (Chicago, IL)
- …experience with Utilization Review ? + Do you have an Active Registered Nurse License? **About US Tech Solutions:** US Tech Solutions is a global staff ... clinical policy, regulatory and accreditation guidelines. + Responsible for the review and evaluation of clinical information and documentation. + Reviews… more
- Molina Healthcare (Long Beach, CA)
- **Job Description** **Job Summary** The Clinical Correspondence Review Nurse is responsible for performing quality reviews of written clinical determination ... regulatory guidelines or requirements, and NCQA accreditation standards, for assigned Medicare , Medicaid or Marketplace programs. **We are seeking a candidate with… more
- US Tech Solutions (May, OK)
- …clinical policy, regulatory and accreditation guidelines. . Responsible for the review and evaluation of clinical information and documentation. . Reviews ... Care cases across all lines of business (Commercial and Medicare ). . Independently coordinates the clinical resolution with internal/external.... 1+ years of inpatient hospital experience . Registered Nurse in state of residence . Must have prior… more
- State of Maine, Bureau of Human Resources (ME)
- MaineCare Quality Review Nurse Maine, USA | Nursing | Full-time Apply by: Sept. 20, 2024 Apply with Linkedin Apply Department of Health and Human Services ... yes and you are licensed as a Registered Professional Nurse in the State of Maine as issued by...this position, please contact Sue Pinette, Asst. Director, Division Medicaid/ Medicare Services at ### or by e-mail at ###@maine.gov.… more
- CommonSpirit Health Mountain Region (Durango, CO)
- …leaders who care about your success. Assist with training and coordinating clinical review and quality assurance. Lead and review the appropriateness of clinical ... care and documentation practices related to patients/residents. Review and evaluate quality data to determine areas needing...of the home health and/or hospice patient. + Registered Nurse + Valid CO Driver's License. + BLS Sedentary… more
- Rising Medical Solutions (Chicago, IL)
- …was born - and continues to thrive. Rising Medical Solutions is looking for a Nurse Auditor who wants to make their mark in the world of medical cost containment. ... team and maximize client savings by reviewing medical bills from a nurse perspective, including appropriate billing, coding and treatment, fee schedule compliance,… more
- Centene Corporation (Sacramento, CA)
- …teams on projects within utilization management as part of the clinical review team + Partners and works with Medical Affairs and/or Medical Directors ... diagnoses, prognoses, resources, and/or preferences + Manages and maintains concurrent review findings, discharge plans, and actions taken on member medical records… more
- Albany Medical Center (Albany, NY)
- …documents findings based on Departmental standards.* While performing utilization review identifies areas for clinical documentation improvement and contacts ... Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies.* Facilitates removal of delays and documents… more
- InnovaCare (Ponce, PR)
- …passion and customer focus to the business. POSITION DESCRIPTION The Quality Specialist Nurse is responsible for monitoring quality of care and services delivered to ... reviews in accordance with the policies and procedures. Performs medical record review in physician's offices of selected HEDIS sample. Performs follow audit to… more
- New York State Civil Service (Greenburgh, NY)
- …Agency People With Developmental Disabilities, Office for Title Licensed Practical Nurse (NY HELPS) Occupational Category Health Care, Human/Social Services Salary ... license and current registration to practice as a practical nurse in New York State, OR B: A limited...on any of the Federal and/or State Medicaid and Medicare exclusion lists (or excluded from any other Federal… more
- Medical Mutual of Ohio (OH)
- …insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans. **Applies process ... for Quality Assurance (NCQA), accreditation standards and the Centers for Medicare & Medicaid Services (CMS) regulations for quality. Performs medical record… more
- LA Care Health Plan (Los Angeles, CA)
- …for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Process the case thru to effectuation and final case ... Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department:...in a manner consistent with LA Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit… more
- Commonwealth of Pennsylvania (PA)
- Health Care Nurse Surveyor Print (https://www.governmentjobs.com/careers/pabureau/jobs/newprint/4553498) Apply Health Care Nurse Surveyor Salary $66,250.00 - ... of Nursing Care Facilities (NCF) as a Health Care Nurse Surveyor and support the department's mission to promote...on-site revisit surveys, civil rights surveys, special Centers for Medicare & Medicaid Services (CMS) surveys, and occupancy surveys… more
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