- Healthfirst (NY)
- …institution or equivalent work experience + NYS RN + Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care ... management for all utilization management functions, including prior authorization, concurrent review , and service requests + Lead, coach, and develop UM… more
- Centers Plan for Healthy Living (Margate, FL)
- …applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a multidisciplinary team to help ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will assess and process all authorization requests to determine medical… more
- Centene Corporation (Jefferson City, MO)
- …experience with ensuring high quality medical director training to review Medicare UM and appeals, Clinical review quality oversight and management. + ... Assist in the development and implementation of physician education with respect to clinical issues and policies. + Identify utilization review studies and… more
- UCLA Health (Los Angeles, CA)
- …clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...benefit coverage. + Applies UCLA Health protocols and national clinical guidelines (eg, InterQual, Milliman) in review … more
- Dignity Health (Bakersfield, CA)
- …superior customer service in line with CommonSpirit's values. You will function as a UM nurse reviewer , applying clinical expertise to ensure appropriate ... reviewing medical records, authorizing services, and preparing cases for physician review . You'll work closely with both Pre-Service and In-Patient Utilization… more
- Integra Partners (Troy, MI)
- …Oversight + Provide day-to-day clinical leadership and oversight to the Utilization Review Medical Director(s) and clinical UM team. + Ensure consistent, ... clinical quality monitoring. + Serve as the clinical reviewer for audit findings and contribute...case review + Prior leadership experience overseeing clinical staff or UM operations + Experience… more
- Evolent (Lansing, MI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member...medical management activities in a managed care environment + UM /UR experience + Clinical experience in Oncology,… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership in other areas of BCBSMA. The physician ... determination depends, making reasonable efforts to obtain relevant information via UM clinical reviewers, peer-to-peer outreach, and/or direct provider EMR… more
- Point32Health (Canton, MA)
- …issues with pharmacy technicians and confer with other clinical pharmacist on review questions + Communicate with UM staff and providers when issues arise ... . **Job Summary** Under the direction of the Pharmacy Utilization Management ( UM ) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing ... obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and… more
- RxBenefits (Charlotte, NC)
- …the effects this has on formulary tier changes, specialty designations, LDD designations, UM components, clinical outcomes, and MCAP outcomes and their relation ... GTM documents with ease and a delivery that exudes confidence around pricing, UM caveats, Clinical Products, and formulary disruption down to the single… more
- CareFirst (Baltimore, MD)
- …**PURPOSE:** The role of the Nurse, Quality Review Utilization Management ( UM ) is to evaluate clinical quality and procedures within the Utilization ... and maintains systematic audit tools to measure compliance with UM Standard Operating Procedures, regulatory requirements and accreditation standards. Utilizes… more
- Insight Global (New York, NY)
- …fully remote Physician Reviewers for a leading health insurance company. The Physician Reviewer will review requests for care before, during, and after treatment ... we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/. Skills and… more
- Healthfirst (NY)
- …Medicaid and//or Managed Long-Term Care Plan (MLTCP). + Demonstrated understanding of UM regulatory requirements, clinical review process, and managed ... **Duties/Responsibilities:** + Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations,… more
- Fallon Health (Worcester, MA)
- …MassHealth (Medicaid contractual agreements). + Responsible for hiring appropriate non-physician clinical and non- clinical personnel to review medical ... operations, including but not limited to prior authorization, concurrent review and discharge planning. + Ensures that members get...with VP/ Medical Director to set agenda related to UM and represent the plan at clinical … more
- CVS Health (Hartford, CT)
- …supports the implementation of strategic initiatives for the Utilization Management ( UM ) Clinical Services organization. These initiatives leverage advanced ... in Utilization Management or clinical operations. + Familiarity with clinical workflows, utilization review processes, and InterQual/MCG guidelines. +… more
- Elevance Health (NC)
- …medically necessary quality behavioral healthcare in a cost-effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer ... companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a comprehensive… more
- Elevance Health (Los Angeles, CA)
- …necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer Reviewers ... and outpatient professional treatment health benefits through telephonic or written review . **How you will make an impact:** + Uses appropriate screening… more
- Integra Partners (Troy, MI)
- The UM Coordinator assists and supports the clinical team ( UM Nurses/Medical Director) with administrative and non- clinical tasks related to processing ... authorization sand appeals. JOB RESPONSIBILITIES + Monitor incoming faxes + Enter UM authorizations review requests in UM platform using ICD-10 and HCPCS… more
- University of Southern California (Alhambra, CA)
- …disposition form for medicare patients timely. + Consultant 1. Demonstrates sound clinical knowledge base regarding CM standards, UM standards, clinical ... competency testing. 8. Perform telephonic, and if appropriate, on-site initial/concurrent review on identified in-patient members. Direct pertinent clinical … more