- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor ( RN ) directs and coordinates the accurate implementation of the clinical appeal ... and serves as a resource for associates within the Clinical Appeals and Analysis unit supporting Government...**Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse -… more
- CareFirst (Baltimore, MD)
- …experience is required in addition to the required work experience. **Licenses/Certifications:** + RN - Registered Nurse - State Licensure And/or Compact ... for our membership, and support NCQA accreditation and the Divisional Goals for the Clinical Appeals and Grievance department. We are looking for an experienced… more
- R1 RCM (Chicago, IL)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Appeals and Denials Manager** , you will serve as ... an expert on clinical appeals and denials management. Every day...trends, challenges, and process improvement opportunities. **Required Skills:** + Registered Nurse (active or inactive in good… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes ... regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes ...**Education Level:** High School Diploma or GED. **Licenses/Certifications:** + RN - Registered Nurse -… more
- 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 ... of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity...external review, and making recommendations for change. QUALIFICATIONS: + Registered Nurse , Physician Assistant or Nurse… more
- RWJBarnabas Health (Oceanport, NJ)
- Clinical Appeals , RN , RemoteReq #:0000173624 Category:Billing/Collections/Registration Status:Full-Time Shift:Day Facility:RWJBarnabas Health Corporate ... is an integral part of our company's success. The RN of Appeals within the RWJ Barnabas...medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...or health plan. Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California,… more
- R1 RCM (Boise, ID)
- …encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse ** , you will help ... position. **Here's what you will experience working as a Clinical Coding Appeals Nurse :** +...external compliance deadlines are met. **Required Skills:** + Active Registered Nurse license + **Active AHIMA or… more
- LA Care Health Plan (Los Angeles, CA)
- …an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and unrestricted ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US,… more
- HonorHealth (Scottsdale, AZ)
- …institution Required Experience 2 years RN experience Required Licenses and Certifications Nursing\ RN - Registered Nurse - State Licensure And/Or Compact ... urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization,… more
- VNS Health (Manhattan, NY)
- …Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + ... Health Plans is seeking a dedicated Manager, Grievance and Appeals ( RN )to lead the daily operations of...+ License and current registration to practice as a registered professional nurse in New York State… more
- LA Care Health Plan (Los Angeles, CA)
- … 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...under the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director. This… more
- MetroHealth (Cleveland, OH)
- …and customer service standards of the MHS.** Qualifications: Bachelor's degree in nursing. Current Registered Nurse License State of Ohio. Minimum of 5 years ... and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the...clinical experience. Knowledge and experience with medical necessity criteria… more
- LA Care Health Plan (Los Angeles, CA)
- …The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse ( RN ) II provides direct assistance to member's with ... Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Department: CSC...agencies. Good working knowledge of regulatory requirements/standards. Licenses/Certifications Required Registered Nurse ( RN ) - Active,… more
- MetroHealth (Cleveland, OH)
- …socioeconomic backgrounds Preferred: Currently licensed or licensed by endorsement as a LPN, Registered Nurse , MD or MD equivalent. Minimum 5 years acute ... departments and more than 20 health centers.** **Summary:** **Performs secondary clinical chart reviews, resolves DRG discrepancies, and educates clinical … more
- BrightSpring Health Services (Louisville, KY)
- …management. This position will also support detailed level reporting and analytics, clinical appeals , root cause analysis, and address identified trends in ... Denials Management and Audit supervises a team of RN /LPN clinical reviewers as well as Support...as well as Support staff managing all areas of clinical claim pre and post audit, appeals … more
- Magellan Health Services (Hodge, LA)
- …State Licensure - Care Mgmt, PT - Physical Therapist, State Licensure - Care Mgmt, RN - Registered Nurse , State and/or Compact State Licensure - Care ... care. Oversees utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the...policies and processes. Also oversees the health plans 24/7 Nurse Line program and the clinical management… more
- CareFirst (Baltimore, MD)
- …+ Reviews Clinical Appeals and Grievances documentation written by the clinical appeals nurse and non- clinical supporting team members within ... evaluate clinical quality and procedures within the Clinical Appeals & Grievance Department Government Programs...addition to the required work experience. **Licenses/Certifications:** + Health Services\ RN - Registered Nurse -… more
- Stanford Health Care (Palo Alto, CA)
- …**This is a remote Stanford Health Care job.** **A Brief Overview** The Utilization Management Registered Nurse (UM RN ) will be responsible for ensuring the ... Stay current with regulatory policies and guidelines related to clinical appeals . + Apply regulatory knowledge to...systems and other healthcare software. **Licenses and Certifications** + Nursing/ RN - Registered Nurse -… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …a systems and implementations team. FEP is BCBSMA's single largest account Position Summary: The RN Clinical Provider Post Service Review Manager , led by a ... a member and provider call center, provider correspondence and appeals , clinical review, member correspondence and reconsiderations,...Registered Nurse , is responsible for a team… more
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