- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- Cognizant (Boston, MA)
- …have to be considered** + Educational background - Registered Nurse ( RN ) + 2-3 years combined clinical and/or utilization management experience with ... Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact...care revenue cycle or clinic operations + Experience in utilization management to include Clinical Appeals and… more
- CenterWell (Boston, MA)
- … RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers...DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous… more
- CVS Health (Boston, MA)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Beth Israel Lahey Health (Burlington, MA)
- …the medical necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized ... Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the...necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue… more
- Beth Israel Lahey Health (Cambridge, MA)
- …SKILLS, AND ABILITIES REQUIRED** 1. RN with experience in risk management , quality assessment, or utilization management . 2. Strong spreadsheet, ... on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of...reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review … more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …true colors to blue. The Role:The Compliance Program Consultant will focus on utilization management compliance and audit readiness activities such as evaluating ... Medical Management 's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations. The Team:… more
- Massachusetts Institute of Technology (Cambridge, MA)
- …patients, families, providers, and community agencies. PREFERRED: two years of case management , utilization review , and discharge planning experience. ... Registered Nurse , Care Coordinator + Job... Registered Nurse , Care Coordinator + Job Number: 25320 +...Graduate of an accredited nursing program; bachelor's degree; current RN license in Massachusetts; CPR Certified; a minimum of… more
- Beth Israel Lahey Health (Burlington, MA)
- …**Essential Duties & Responsibilities including but not limited to:** 1) Performs utilization review and discharge planning to inpatient admissions. 2) Applies ... to meet the needs of the department. **Minimum Qualifications:** Education: * Registered Nurse , Bachelors Degree or commensurate experience preferred. Licensure,… more
- Tufts Medicine (Melrose, MA)
- …role is essential in developing and maintaining an infrastructure for the systematic review and management of complex patients. The position will work closely ... managers, TMIN Practice Optimization Coaches (POMs) and primary care providers to review patient records, analyze data, and identify practice and patient outlier … more
- Lawrence General Hospital (Methuen, MA)
- … experience in an acute care setting with discharge planning, continuing care, care management , and utilization review preferred. ? Strong verbal and written ... Job Description: The RN Care Coordinator is responsible for overseeing the...of the Hospital on a rotating basis to perform utilization reviews and other UM activities, as needed, to… more
- Fresenius Medical Center (Lowell, MA)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …and 3-5 years in a managed care health plan setting. + Strong understanding of Utilization Review , Care Management and Medical Polices. + Knowledge of APR ... concerns Key Qualifications + Strong clinical skills and understanding of HMM's Utilization Management , Case Management and operational procedures, Medical… more
- Fresenius Medical Center (Peabody, MA)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Beth Israel Lahey Health (Needham, MA)
- …practice model. **Job Description:** **Essential Responsibilities:** 1. Performs utilization management , care coordination, and discharge planning ... third weekend & rotating holiday required) Job Summary: The RN Case Manager (CM) facilitates the coordination of care.... 4. Knowledge of discharge planning practices, understanding of utilization review practices including third party payer… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. * Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management * Serve as the primary relationship manager and point of contact… more
- Evolent (Boston, MA)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators...Be Doing:** + Practices and maintains the principles of utilization management and appeals management … more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred. + Active licensure in Massachusetts is ... Bring your true colors to blue. The Role The RN Case Manager is responsible for facilitating care for...standards to create, follow and appropriately document comprehensive care management plans. + Review medication list and… more
- Highmark Health (Boston, MA)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder… more