- Humana (Raleigh, NC)
- …of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent… more
- CVS Health (Raleigh, NC)
- …And we do it all with heart, each and every day. **Position Summary** Utilization Management is a 24/7 operation and work schedules will include weekends, ... holidays, and evening hours. * Utilizes clinical experience and skills in a collaborative process to...and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and… more
- CenterWell (Raleigh, NC)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Evolent (Raleigh, NC)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… 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 ... or chronic kidney disease. **Training and advancement:** You will enter our Clinical Leadership Program that creates and supports a culture of continuous learning… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Primary Responsibilities + Adheres to regulatory regulations (eg, ERISA, HIPAA) for Case Management and self-insured clients. + Uses clinical tools for patient ... Case Management . + Determines appropriate care level and resource utilization for complex cases. + Facilitates discharge planning and evaluates alternative… more
- UNC Health Care (Chapel Hill, NC)
- …serve. The individual selected for this position will function as a Neonatal Nurse Practitioner (NNP) delivering critical care medical management in the Newborn ... by identifying and implementing processes for improvement. Consults with management in assessment, problem-solving, decision-making, and evaluating clinical… more
- CVS Health (Raleigh, NC)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... self-insured clients. + Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures… 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' ... services for timely return to work. + Provides case management , utilization review, continued stay reviews, and...utilization review, continued stay reviews, and based on clinical judgment and state WCB Medical Treatment Guidelines. +… more
- CenterWell (Lillington, NC)
- …you to sit on-site at our Lillington, NC branch location.** The **RN Clinical Manager** coordinates and oversees all direct care patient services provided by ... clinical personnel. This role is a focused on both... documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates… more
- Deloitte (Raleigh, NC)
- … registered nurse , physician, physician assistant, case manager, clinical documentation specialist, utilization review, informatics RN, Quality, DRG ... and informal education of physicians, CDI team, health information management and other clinical staff + Develop...medical degree, or physician assistant required + Current Registered Nurse (RN) license required + Certified Clinical … more
- UNC Health Care (Chapel Hill, NC)
- …and Care Management Assistants. + Candidate must be a **Registered Nurse (RN)** or **Licensed Clinical Social Worker (LCSW/LCSWA)** + Preference given ... for designated Clinical Care Management Department team(s). Provides management direction to Case Managers, Utilization Managers, Clinical Social… 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 ... supporting cost-effective discharge planning. + Serve as a key resource in case management , utilization review, and discharge planning. + Stay compliant with all… more
- Sharecare (Raleigh, NC)
- …3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case ... / new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical,… more
- UNC Health Care (Chapel Hill, NC)
- …through the integrating and functions of point of entry case management , utilization review, and effective patient flow activities. Responsibilities: ... implement a hospital wide capacity management strategy. 3. Logistics Management - Collaborate with house supervisors and clinical admitting decision makers… more
- Oracle (Raleigh, NC)
- …of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will ... These include, but are not limited to, multiple Essential Clinical Dataset (ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding,… more
- Highmark Health (Raleigh, NC)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... data to assure appropriate level of payment and resource utilization . It is also used to identify issues which...- 5 years of related, progressive experience in a clinical setting **Preferred** + 1-3 years of experience in… more
- UNC Health Care (Garner, NC)
- …7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely ... plans are evidence-based, culturally sensitive, and promote patient engagement and self- management . 3. Risk Segmentation: a. Utilize standardized tools and … more