- Point32Health (Canton, MA)
- …leading, and modifying the business processes and operations for all levels of utilization management review (ie, Precertification and Intake Services, ... perform the job** **Education, Certification and Licensure** + Master's degree preferred. + RN ( Registered Nurse ) with unrestricted MA license preferred. +… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... in the area of service decisions and organizational determinations.The Manager, Utilization Management reports to the Director of Clinical Effectiveness.… more
- Humana (Boston, MA)
- …a part of our caring community and help us put health first** The Utilization Management Behavioral Health Nurse uses behavioral health knowledge and ... be located and licensed in a Compact State** The Utilization Management Behavioral Health Nurse ...Qualifications** + Minimum of Associate Degree in Nursing + Registered Nurse ( RN ) licensure with… more
- Commonwealth Care Alliance (Boston, MA)
- …clinical and service authorization review for medical necessity and decision-making. The Utilization Management Reviewer has a key role in ensuring CCA ... services, procedures, and facilities under the provisions of CCA's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day… more
- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... provisions of CCA's benefits plan. The Nurse Utilization Management (UM) Reviewer is...**What You'll Be Doing:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Brockton Hospital (Brockton, MA)
- …responsibilities. EDUCATION: + RN with Master's Degree + Current License as Registered Nurse in the Commonwealth of Massachusetts EXPOSURE CATEGORY: It is ... management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience… more
- Fresenius Medical Center (Medford, 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
- Humana (Boston, MA)
- … RN , Compliance Nurse 2, Quality Assurance Auditor reviews utilization management activities and documentation to ensure adherence to policies, ... an acute care, skilled and/or rehabilitation clinical setting + Experience with utilization management , pre-service denials and/or quality assurance audits +… more
- Veterans Affairs, Veterans Health Administration (Bedford, MA)
- …considered and referred as vacancies become available. This OCA may be used to fill a Registered Nurse ( RN ) position that is located in the one of following ... VHA Education Loan Repayment Services program office after complete review of the EDRP application. Responsibilities VA offers a...CLC-2C CLC-62C CLC-62D CLC-78C The Community Living Center (CLC) Registered Nurse ( RN ) is responsible… more
- Beth Israel Lahey Health (Cambridge, MA)
- …just taking a job, you're making a difference in people's lives.** Registered Nurse - Emergency Department **Job Description:** **Primary Responsibilities** 1. ... The emergency nurse initiates accurate and ongoing assessment of physical, psychological...c. Maintains BLS, ACLS certification d. Attends Emergency Department RN Competency Review Course annually. e. Attends… more
- Edward M. Kennedy Community Health Center, Inc. (Framingham, MA)
- …require evening, weekend and/or holiday shifts on a rotating basis. Required Qualifications: + Registered Nurse License in MA + Bachelor's degree in Nursing from ... are currently hiring a Clinical Care Manager - OBAT RN based in Framingham. As part of a team-based...Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to Medical Assistant Treatment Program (MAT) patients. As… 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
- WTW (Boston, MA)
- …Third Party Administrator, Regulatory Agency, Legal/Compliance Firm, or insurance company + US Registered Nurse or LCSW with active licensed preferred + Health ... reviewed including master templates and client specific responses + Collaborate with health management senior reviewer and Project Manager to conduct follow up… more
- Tufts Medicine (Burlington, MA)
- …**Job Description** **Minimum Qualifications:** 1. Bachelor's Degree in Nursing 2. Active Registered Nurse ( RN ) license in Massachusetts or compact ... (ICU, ED, Critical Care, strong Med/Surg Specialty) or equivalent case management , utilization review , denials management , or progressive leadership… more
- Erickson Living (Peabody, MA)
- …clinical leadership meetings such as Wound Rounds, Clinical Operations Meeting, Utilization Review , and Performance Improvement/Risk Management /Safety ... and processes in accordance with the Erickson Senior Living Management Policies and Procedures and nursing standards of practice....care, assisted living or hospital) is required. + Current Registered Nurse license for the state in… more
- Prime Therapeutics (Boston, MA)
- …oversight for this program is provided by the Manager, Patient Programs. **Responsibilities** + Registered Nurse ( RN ). + 5 years of post-degree clinical ... experience. + Experience in managed care, specialty drugs, care management and utilization review . +...- Preferred: Bachelors - Nursing **Certifications** Certifications - Required: RN - Registered Nurse , State… more
- Elevance Health (Woburn, MA)
- …**How you will make an impact:** + Develops, maintains and enhances the claims review process. + Assists management with developing unit goals, policies and ... ** RN Hospital Bill Audit/Appeal Lead** **Supports the Carelon...responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through… more
- Beth Israel Lahey Health (Beverly, MA)
- …care givers, and families. Their functions include concurrent and retrospective review to assure appropriate utilization , assessment, prevention of denials ... school of nursing 2. BSN preferred **Certification/License:** 1. Current Massachusetts RN licensure 2. Certification in Case Management preferred **Patient… more
- East Boston Neighborhood Health Center (East Boston, MA)
- …range planning and determining staffing needs. + Assists Home Care Manager/Residential Nurse manager to monitor utilization and processes for stocking Nursing ... in policy review and revision. Works with Home Care Director/Residential Nurse Manager to update policies, procedures and workflows as needed to ensure… more
- Elevance Health (Boston, MA)
- …managing the clinical operations department. Manages the delivery of quality care management , clinical utilization and referral services. **Location:** Remote - ... practice that is relevant to the clinical areas under review . + Identifies areas for quality improvement and implements...unrestricted license in a mental health field as an RN , PhD, LCSW (as applicable by state law and… more