- CenterWell (Raleigh, NC)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Humana (Raleigh, NC)
- …and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and ... caring community and help us put health first** The Utilization Management Nurse 2 utilizes...extends outside of work. Among our benefits, Humana provides medical , dental and vision benefits, 401(k) retirement savings plan,… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Case Management . + Determines appropriate care level and resource utilization for complex cases. + Facilitates discharge planning and evaluates alternative ... educator, Pediatric Nursing, Gerontological Nursing, Maternity Nursing, Population health, Disease Management . + Current licensed Registered Nurse (RN) with… more
- Evolent (Raleigh, NC)
- …criteria sets (ie, Milliman, InterQual) + Minimum of one year of experience with medical management activities in a managed care environment + UM/UR experience + ... utilization reviews of **Oncology treatment requests** + Determines medical necessity and appropriateness of services using clinical review criteria. +… more
- Fresenius Medical Center (Cary, NC)
- …and acting on adverse events and action thresholds in collaboration with facility management . + Maintains integrity of medical records and other organization ... direction of the Facility Manager, Director of Nursing and/or Charge Registered Nurse , utilizing standard nursing techniques to assist the physician in optimum… more
- Fresenius Medical Center (Raleigh, NC)
- …and acting on adverse events and action thresholds in collaboration with facility management . + Maintains integrity of medical records and other FVC ... procedure, under the direction of the Facility Manager and/or Charge Registered Nurse , utilizing standard nursing techniques to assist the physician in optimum… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review/ Medical and Case Management services for Workers' Compensation. The Workers' ... Compensation Nurse Case Reviewer collaborates with medical care providers, employers, employees, and at times, attorneys...services for timely return to work. + Provides case management , utilization review, continued stay reviews, and… more
- UNC Health Care (Chapel Hill, NC)
- …will function as a Neonatal Nurse Practitioner (NNP) delivering critical care medical management in the Newborn Critical Care Center based at the North ... **Description** Have you considered a Neonatal Nurse Practitioner career with UNC Health? This opportunity...accreditation standards. The practitioner has responsibility for complete daily medical management of a caseload of critically… more
- Fresenius Medical Center (Garner, NC)
- **About this role:** As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical operations. ... a tremendous asset that sets us apart. At Fresenius Medical Care, you will truly make a difference in...Disease (ICD) coding. + Manages clinic financials including efficient utilization of supplies or equipment and regular profits and… more
- Humana (Raleigh, NC)
- …Office products including Word, Excel and Outlook **Preferred Qualifications** + Utilization Review/Quality Management experience + Experience working with MCG ... a part of our caring community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work assignments… more
- CVS Health (Raleigh, NC)
- …health literacy, technology capabilities, and/or readiness to change. Enhancement of Medical Appropriateness & Quality of Care: -Application and/or interpretation of ... applicable criteria and guidelines, health/wellness management plans, policies, procedures, regulatory standards while assessing benefits and/or member's needs to… more
- Actalent (Cary, NC)
- …+ Triage skills + Acute care + Oncology nursing + RN license + Utilization management + Patient education Additional Skills & Qualifications + Registered ... Job Title: Telehealth NurseJob Description As a Telehealth Nurse , you will counsel and educate new and...for this temporary role may include the following: * Medical , dental & vision * Critical Illness, Accident, and… more
- UNC Health Care (Chapel Hill, NC)
- …**Professional Experience Requirements:** * Five (5) years of experience in care management , utilization management , discharge planning, care coordination, ... and Care Management Assistants. + Candidate must be a **Registered Nurse (RN)** or **Licensed Clinical Social Worker (LCSW/LCSWA)** + Preference given to… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …for the Casualty and Clinical Services departments which in turn includes Utilization Management , Case Management and Population Health divisions. ... Review (UR) Programs. + Collaborates with the Chief Medical Officer on evaluation of departmental policies and procedures... management of a clinical team. + Previous Utilization Management experience required. + Previous experience… more
- CenterWell (Lillington, NC)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts ... problems, identifies and evaluates alternative courses of action through the utilization of Performance Improvement principles. + Responsible for review of the… more
- UNC Health Care (Chapel Hill, NC)
- …7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely ... planning. + Serve as a key resource in case management , utilization review, and discharge planning. +...level of patients based on various factors such as medical conditions, social determinants of health, and behavioral health… more
- Highmark Health (Raleigh, NC)
- …Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health ... RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). + Delaware RN license must...is part of the compact **Preferred** + Certification in Utilization Management or a related field **SKILLS**… more
- Sharecare (Raleigh, NC)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to ... present premier provider options, including but not limited to medical , dental, and vision plans + Support for spending...+ Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex… more
- Datavant (Raleigh, NC)
- …computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus. Minimum Education: LVN/LPN + ... of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for...management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in… more
- Deloitte (Raleigh, NC)
- …Informatics, Business Administration, Nursing and related health fields preferred + Case Management or Medical coding certification a plus (CRC, CCA, CCS-P, ... to collaborate with clinicians, physicians, NP/PAs, ancillary departments, Quality, Case Management , Finance, Revenue Cycle, and Coders + Other skills include the… more