- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …(Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred + Experience with Medicare Advantage, preferred + ... help us transform healthcare? Bring your true colors to blue. The RoleThe Clinical Utilization Reviewer is responsible for facilitating care for our Medicare … more
- UCLA Health (Los Angeles, CA)
- …level. You can do all this and more at UCLA Health. As a Manager for Medicare Advantage Utilization Management , you'll provide direct management to a ... of UM coordinators and nurses. You'll work closely with Medicare Advantage leadership to plan, execute, and manage various...HMO environment + Thorough knowledge of health care industry, utilization review , utilization management… more
- UCLA Health (Los Angeles, CA)
- Description As the Utilization Management & Quality Review Nurse, you will be responsible for: + Ensuring appropriate, cost-effective, and high-quality care ... California RN license, required * Two or more years of experience in utilization management , preferably in Medicare Advantage or managed care * Knowledge of… more
- Medical Mutual of Ohio (OH)
- …to work at home. We are looking for applicants that have a strong clinical utilization management background. Medicare experience is a plus. **Founded in ... care at the most appropriate time + Keeps up to date on utilization management regulations, policies, and practices, including applicable coding + Performs… more
- Evolent (Columbus, OH)
- …clinical objectives **Desired Skill Set** + Understanding of regulatory framework for utilization management in Medicare , Medicaid, and Commercial contexts ... of physician, nursing, and shared services staff in the utilization management value chain + Owns clinical...and implementation of new strategies to make the clinical review process more efficient through people, processes, and technology… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …Active clinical practice in order to participate in panel appeals + Experience in Utilization Management in a managed-care environment (as a clinician or in ... of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical...to evaluate clinical service requests + Practice anticipatory case management for members whose cases come for review… more
- Evolent (Columbus, OH)
- …Doing:** As a Physician Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Elevance Health (Miami, FL)
- …in an ambulatory or hospital setting or minimum of 1 year of prior utilization management , medical management and/or quality management , and/or ... applicable state(s) required. **Preferred Skills, Capabilities & Experiences:** Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and… more
- Centers Plan for Healthy Living (Margate, FL)
- …currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will...to enroll eligible individuals who are either Medicaid or Medicaid/ Medicare recipients and optimize their ability to remain in… more
- LA Care Health Plan (Los Angeles, CA)
- …Coordinates multi-departmental (Member Services, Product Network Operations (PNO), Claims, Utilization Management (UM), Pharmacy, Medicare ... department and Plan Partners: Department of Health Services (DHS), Centers for Medicare and Medicaid Services (CMS) National Committee Quality Assurance (NCQA) as… more
- CaroMont Health (Gastonia, NC)
- …license to practice in NC (NC license or multi-state (compact) license). Certification in Utilization Review / Management , Quality and/or Case Management ... to MCO via fax, Provider Link, or telephonically. Gathers and disseminates Utilization Management information to medical staff departments, Nursing departments,… more
- Hackensack Meridian Health (Hackensack, NJ)
- …Hackensack UMC. These include but are not limited to utilization review , hospital reimbursement, clinical compliance, case management , and transitions of ... on length of stay, level of care requirements and Medicare regulations, and Major Complications or Comorbidities (MCC) /...ie MCG, Xsolis) b. Supports & Participates in pre-admission review , utilization management , and concurrent… more
- Hackensack Meridian Health (Hackensack, NJ)
- …Hackensack UMC. These include but are not limited to utilization review ,** **hospital reimbursement, clinical compliance, case management , and transitions of ... Criteria ( ie MCG,** **Xsolis)** **b. Supports & Participates in pre-admission review , utilization management , and concurrent and** **retrospective … more
- Behavioral Center of Michigan (Warren, MI)
- Under general supervision, the Utilization Review Coordinator provides professional assessment, planning, coordination, implementation and reporting of complex ... clinical data and supports the operations of Samaritan Behavioral Center. The Utilization Review Coordinator reviews the patient's chart and records clinical… more
- Humana (Columbus, OH)
- …a part of our caring community and help us put health first** The Utilization Management Registered Nurse 2 utilizes clinical nursing skills to support the ... and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and… more
- Stanford Health Care (Palo Alto, CA)
- …Skills and Abilities** + Knowledge of principles and best practices of case management , utilization review , social work, care coordination and discharge ... practice. Here, your leadership, coaching, and mentoring would further develop our robust, Utilization Management team. Are you driven by health care innovation,… more
- Martin's Point Health Care (Portland, ME)
- …has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as a member of a team responsible for ensuring ... reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well… more
- US Tech Solutions (Chicago, IL)
- …MANAGED CARE exp and Medicare /Medicaid knowledge. + MUST HAVE UM experience, inpatient utilization management review . + MUST HAVE 1 YEAR OF ... UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG. + MUST HAVE...with Prior Authorization? + Do you have experience with Utilization Review ? + Do you have an… more
- Molina Healthcare (San Bernardino, CA)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... IT and data analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory, professional and community… more