- CVS Health (Augusta, ME)
- …we do it all with heart, each and every day. **Position Summary:** The ** Utilization Management Clinical Nurse Consultant - Prior Authorization** utilizes ... Time_ ). + Previous experience with prior authorization. + Previous experience with utilization management . + Previous experience in an acute care setting. +… more
- Cognizant (Augusta, ME)
- …background - Registered Nurse (RN) + 2-3 years combined clinical and/or utilization management experience with managed health care plan + 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations + Experience in utilization management to include Clinical Appeals and… more
- Martin's Point Health Care (Portland, ME)
- …of clinical nursing experience as an RN, preferably in a hospital setting + Utilization management experience in a health plan UM department Required License(s) ... "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as is responsible...to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective… more
- CVS Health (Augusta, ME)
- …we do it all with heart, each and every day. Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of ... efficient use of healthcare resources. Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of… more
- CVS Health (Augusta, ME)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Abuse or Maternity/ Obstetrics experience. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… more
- Northern Light Health (South Portland, ME)
- …Collaborates with the interdisciplinary team to maximize patient care. + Resource Management - Identifies opportunities to improve utilization of resources. + ... out incrementally after successful completion of probationary period Summary: The Registered Nurse II is a fully competent practitioner of nursing. The incumbent is… more
- Evolent (Augusta, ME)
- …Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed ... medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum… more
- Evolent (Augusta, ME)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and… more
- CenterWell (Portland, ME)
- …driver's license, auto insurance and reliable transportation. + Two years as a Registered Nurse with at least one-year of management experience. + Home health ... review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts… more
- Sharecare (Augusta, ME)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Highmark Health (Augusta, ME)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... itemized bills, and claims data to assure appropriate level of payment and resource utilization . It is also used to identify issues which can be used for education… more
- CVS Health (Augusta, ME)
- …health outcomes by engaging telephonically with individuals living with diabetes. This nurse will guide members through actionable steps to close gaps in care, ... education, connecting members to resources, and facilitating referrals to care management programs for continued support. This position supports the development and… more
- Oracle (Augusta, ME)
- …alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal candidate ... sessions, and offer ongoing consultation to support user proficiency and system utilization . Monitor project outcomes, track key metrics, and report progress to… more