- CVS Health (Boston, MA)
- …- hospitals, outpatient networks, and value-based care relationships. The Medical Director will be responsible for overseeing the utilization review for health ... in-hospital utilization reviews and other quality activities. The Medical Director will be required to have a Massachusetts state...of the states in the New England Region *Previous UM experience with a Health Plan / Payor. *Previous… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …+ Apply their clinical knowledge when assessing/auditing medical records and UM letters against medical necessity criteria and accreditation and regulatory criteria ... + Accurately plan and scope projects; keep project leads, senior consultants, and Director informed of key issues/ risks and meet deadlines by tightly managing… more
- Evolent Health (Boston, MA)
- …Through strong organizational practices and attention to detail the Behavioral Health UM Team supports a range of managed care populations including Medicaid, ... Identifies and refers cases not meeting established clinical criteria to the Medical Director Review. + Identifies and escalates quality of care issues to the… more
- Highmark Health (Boston, MA)
- …in the capacity as a clinical pharmacist the incumbent may also review UM requests; provide consultation into the case and disease management identification process, ... overall efficiencies. + Manage individual projects for timely review with the Director , Clinical Pharmacy. + Participate in Medicare Stars performance measures to… more