- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity ... of services and care. * Provides referrals to Case management , Disease Management , Appeals & Grievances, and...a high pace and changing environment. * Proficient in Utilization Review process including benefit interpretation, contract… more
- CVS Health (Raleigh, NC)
- …more personal, convenient and affordable. **Position Summary** **This is a fully remote Utilization Management opportunity.** Utilization management is a ... external constituents in the coordination and administration of the utilization /benefit management function. + Typical office working...in EST or CST + Managed Care experience + Utilization review experience **Education** + Minimum of… more
- Lincoln Financial Group (Raleigh, NC)
- …Experience and/or proficiency with Disability Management (STD/LTD) knowledge, Workers Compensation, Utilization Review and/or nurse case management ... Role at a Glance** We are excited to bring on a highly motivated Nurse Disability Consultant to our clinical organization. This position will be responsible for… more
- UNC Health Care (Raleigh, NC)
- …stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is ... **Description** **Full time exempt, 40 hours per week Utilization Manager - Medical necessity review ...management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization… more
- Centene Corporation (Raleigh, NC)
- …and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- Motion Recruitment Partners (Durham, NC)
- Utilization Management Specialist Durham, NC **100% Remote** Contract $17/hr - $17/hr Our client, a nationally recognized and award-winning company in the health ... insurance vertical, has a contract opening for a Utilization Management Specialist. They have over 4...Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director.… more
- Robert Half Office Team (Durham, NC)
- …industry, located in Durham, North Carolina, and we're looking to bring a Utilization Management Specialist on board. This role involves making outbound calls ... Identify and refer organization determinations that require a clinical review to a nurse or Medical Director....Management System (CMS) and Facets * Knowledge of review processes * Ability to adhere to protocols and… more
- Ciena Healthcare (Pittsboro, NC)
- …hard-working team that values communication and strong teamwork abilities. **Responsibilities:** The Care Management Nurse , MDS Nurse works the RAI process ... Are you an experienced nurse who wants to remain clinically involved in...PPS board for monitoring of Medicare days and RUGs utilization in the absence of the Care Management… more
- Fresenius Medical Center (Durham, NC)
- …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
- UNC Health Care (Raleigh, NC)
- …of care and cost effectiveness through the integrating and functions of case management , utilization review and discharge planning. The Care Manager ... discharge plan. Refer administrative tasks (eg, faxing, form processing) to Care Management Assistant. Consult Social Worker and/or Utilization Manager per… more
- UNC Health Care (Chapel Hill, NC)
- …of care and cost effectiveness through the integrating and functions of case management , utilization review and discharge planning. The Care Manager ... discharge plan. Refer administrative tasks (eg, faxing, form processing) to Care Management Assistant. Consult Social Worker and/or Utilization Manager per… more
- CenterWell (Cary, NC)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking...and reliable transportation. + Two years as a Registered Nurse with at least one-year of management … more
- UNC Health Care (Chapel Hill, NC)
- …of care and cost effectiveness through the integrating and functions of case management , utilization review and discharge planning. The Inpatient Care ... 7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely… more
- Centene Corporation (Raleigh, NC)
- …abuse across the continuum of care. Experience with managed care, case management , utilization management , or quality improvement. **License/Certification:** ... groups and providers regarding clinical information from the Operations and Medical Management teams. Assesses and performs review of member clinical records… more
- UNC Health Care (Chapel Hill, NC)
- …cost effectiveness through the integrating and functions of point of entry case management , utilization review , and effective patient flow activities. ... needs. The overall goal of the position is to enhance the quality of inter-hospital transfer management and satisfaction and to promote continuity of care and… more
- UNC Health Care (Raleigh, NC)
- …cost effectiveness through the integrating and functions of point of entry case management , utilization review , and effective patient flow activities. ... position is to enhance the quality of inter-hospital transfer management and satisfaction and to promote continuity of care...* Must be licensed to practice as a registered nurse in the state of North Carolina **Professional Experience… more
- CVS Health (Raleigh, NC)
- …(typically every 4-6 weeks)** The Health Coach Consultant: Chronic Condition Nurse utilizes a collaborative process of assessment, planning, implementation, and ... You will assess members through the use of clinical tools and information/data review to conduct comprehensive evaluation of needs and benefit plan eligibility for… more