- Commonwealth Care Alliance (Boston, MA)
- …and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA meets ... Summary:** Reporting to the Manager Utilization Management, the Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical… more
- Alameda Health System (Oakland, CA)
- …each individual in the classification. Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations. ... utilization reviews and determine program improvements. Develop and implement utilization review policies and procedures in accordance with industry… more
- Katmai (Fort Carson, CO)
- **SUMMARY** Provide a comprehensive utilization review (UR) and utilization management (UM) program for all TRICARE eligible beneficiaries within the CMHS. ... and the TRICARE Operations Manual (TOM) access to care standards for appropriate utilization of services. Perform utilization management/ review for medical… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …an experienced **MD** to join our team as an **Assistant Medical Director ( Utilization Management - Oncology)** . The AMD will leverage their specialization in ... on medical necessity and contract language for health plan members, including review of clinical documentation using medical policy criteria, guidelines, and member… more
- Harbor Health Services, Inc. (Mattapan, MA)
- …regulatory entities. Collaborates with Senior Medical Director to resolve complex medical review issues and utilization cases requiring elevation to the Senior ... 580 participants. We are currently seeking a Director of Utilization Management & Quality Programs. Harbor Health offers an...Ensures timely responses to all requests related to medical review decisions and authorization issues from EOHHS, CMS and… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …**UM RN Appeals Coordinator.** This role collaborates with clinical review staff, medical directors/physician reviewers, network physicians, and network facilities ... 8:00 AM - 5:00 PM CST (Flexible) **Responsibilities** A. Performs necessary review to ensure compliance with HHSC and other regulatory entities + Collaborate:… more
- Stanford Health Care (Palo Alto, CA)
- …responsibilities include coordinating all facets of a patient's admission/discharge; performing utilization review activities, including review of patient ... other interdisciplinary team members; arranges followup care as appropriate. + Utilization Review -- Reviews prospectively, concurrently and retrospectively all… more
- Stanford Health Care (Palo Alto, CA)
- …responsibilities include coordinating all facets of a patient's admission/discharge; performing utilization review activities, including review of patient ... provide requested clinical and psychosocial information to assurereimbursement. + Utilization Review -- Reviews prospectively, concurrently and retrospectively… more
- Tris Pharma (Monmouth Junction, NJ)
- …other payer contracts, including redlining contract language, coordinating cross-functional review and approval workflows, and ensuring execution consistent with ... contact for IntegriChain (BPO partner), managing data file submissions, utilization reporting, rebate validation processes, and issue escalation to ensure… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …bundling edits, and recommend action steps regarding code configuration issues, annual utilization and review analysis. + Maintain current knowledge of coding ... procedure and diagnosis codes, and support business decisions regarding utilization management activities and guidelines. + Support medical policy development… more
- Christus Health (Euless, TX)
- …success in CHRISTUS RN Care Manager I position. Case management and Utilization Review experience preferred. Licenses, Registrations, or Certifications RN ... effectively to meet patient need, manage length of stay and promote efficient utilization of resources to include the facilitation of patient care across the… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …helping members navigate and understand their benefits related to Appeals, External Medical Review , and the Fair Hearing process. Acts as the first point of contact ... rights and responsibilities including the appeals process, External Medical Review and State Fair Hearing + Stands in as...+ Inputs EMR and Fair Hearing data into the Utilization Management system with accuracy and completeness per established… more
- Washington Metropolitan Area Transit Authority (New Carrollton, MD)
- …space planning and interior design and addresses space needs by conducting utilization analysis and programming. The incumbent will lead the space allocation ... Manages the development and maintenance of WMATA Master Plan for Space Utilization (Non-Operations) and database of current space allocation by department. +… more
- Katmai (Fort Carson, CO)
- …and providers, network/outside providers and ancillary healthcare workers. + Apply principles of utilization review (UR) and utilization management (UM) in ... processing referrals to specialty care. **ESSENTIAL DUTIES & RESPONSIBILITIES** + Review collected data to identify areas requiring intensive management. Analyze… more
- Katmai (Fort Carson, CO)
- …as needed to provide direction in care management. + Plan and prioritize utilization review (UR) activities to ensure identified patient needs are addressed ... analyze, update and record data. + Facilitate the development and integration of utilization management (UM) review policies and procedures into operations. +… more
- Commonwealth Care Alliance (Boston, MA)
- …success. + Conduct regular provider meetings (virtual and in-person) to review performance, discuss program updates, and address operational challenges. + Represent ... + Lead the monitoring and analysis of provider performance using utilization , quality, and member experience metrics. + Collaborate with Business Intelligence,… more
- NORC (Chicago, IL)
- …drug utilization practices and treatment recommendations, clinical practice guidelines review , FDA label review , clinical and oncology pharmacy. + Monitor ... changes to guidelines and assess their impact on drug utilization + Conduct FDA label reviews and synthesize clinical...and promotions, which is overseen by a formal Salary Review Committee (SRC)._ **WHAT WE DO:** NORC at the… more
- University of California Agriculture and Natural Resources (Ventura, CA)
- …Posting Close Date: This job is open until filled. The first application review date will be 12/08/2025. Key Responsibilities: 45% Prepare samples for analysis. ... plots, work to coordinate applications, and maintain plots. 30% Collect and review data on established projects. 15% Ensure the laboratory equipment and supplies… more
- GCI Communication Corp (Juneau, AK)
- …and utilization to meet business and operational needs. + Facilities Utilization & Performance: Regularly review network facilities utilization and ... the software and firmware upgrade/patch process, minimizing operational disruption. + Review and analyze the effectiveness of implemented network and service… more
- GCI Communication Corp (Anchorage, AK)
- …and utilization to meet business and operational needs. + Facilities Utilization & Performance: Regularly review network facilities utilization and ... the software and firmware upgrade/patch process, minimizing operational disruption. + Review and analyze the effectiveness of implemented network and service… more
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