- Molina Healthcare (Atlanta, GA)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- Travelers Insurance Company (Atlanta, GA)
- …Utilize evaluation documentation tools in accordance with department guidelines. + Proactively review Claim File Analysis (CFA) for adherence to quality ... evaluating, reserving, negotiating and resolving assigned serious and complex Specialty claims . Provides quality claim handling throughout the claim… more
- Travelers Insurance Company (Alpharetta, GA)
- …on collaboration. Imagine loving what you do and where you do it. **Job Category** Claim , Nurse - Medical Case Manager **Compensation Overview** The annual ... through a continuous process of management involvement and frequent claim file review . Serve as a field...guidance to ensure effectiveness, engagement, accuracy and efficiency. + Review new notices, ensuring claims are assigned… more
- State of Georgia (Fulton County, GA)
- …additional experience in the analysis of medical services documentation and related claims 2) Utilization Review 3) Case Management 4) Analysis of CPT codes ... Nurse Investigator Georgia - Fulton - Atlanta (https://careers.georgia.gov/jobs/64040/other-jobs-matching/location-only)...clinical experience AND one (1) year experience working with medical claims . Preference will be given to… more
- Molina Healthcare (Atlanta, GA)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location: This is a virtual position. Ideal candidates will reside within 50 miles of an Elevance Health Pulse Point ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for performing care...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location: This is a virtual position. Candidates must reside within 50 miles of an Elevance Health Pulse Point location.** ... in different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the… more
- GE Vernova (Atlanta, GA)
- …project execution and ensures that commercial risks and opportunities (notably claims , change orders, vendor and insurance recoveries) are identified early, tracked, ... **Roles and Responsibilities** + Implement risk mitigation strategies + Develop claims settlement agreements + Manage and drive Contract Change Order execution… more
- Molina Healthcare (Atlanta, GA)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Elevance Health (Atlanta, GA)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- PruittHealth (Norcross, GA)
- …Coordination (DEAC), the Episode Assessment Coordinator (EAC) is responsible for prospective review of episode related documents. The EAC ensures all services and ... utilization meets needs for improved patient outcomes and appropriate claims reimbursement in accordance with regulatory billing guidelines. **KEY… more
- Evolent (Atlanta, GA)
- …and write clearly. + Reviews adverse determinations against criteria and medical policies + Creates adverse determination notifications that meet all accreditation, ... + Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director. + Appropriately identifies potential cases… more
- CVS Health (Atlanta, GA)
- …Direct and oversee complex reviews. Ensure timely and accurate reporting of review findings and coordinate with investigative to take appropriate action. Conducts ... detection, investigation, or auditing In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.… more
- GE Vernova (Atlanta, GA)
- …Negotiate terms and conditions and transmit information to Procurement. Manage claims . Includes commercial sourcing management such as data analysis, negotiations ... and precedents or are covered by well-defined policies or review of end results. The job allows modification of...130% of salary in certain areas. Healthcare benefits include medical , dental, vision, and prescription drug coverage; access to… more