- Dignity Health (Gilbert, AZ)
- …of the Director of Care Management, performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective ... + Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on… more
- CenterWell (Phoenix, AZ)
- …actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that ... RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work… more
- Humana (Phoenix, AZ)
- …Coordinator or discharge planner in an acute care setting + Previous experience in utilization management/ utilization review for a health plan or acute care ... our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination,… more
- Molina Healthcare (Chandler, AZ)
- **Job Description** **Job Summary** The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment ... Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have...clinical nursing experience, including at least 1 year of utilization review , medical claims review ,… more
- Veterans Affairs, Veterans Health Administration (Phoenix, AZ)
- …intimate knowledge of the internal referral care process, clinical review criteria, utilization management standards, clinical documentation requirements, ... as well as customer service programs. Community Care (CC) Coordinator Registered Nurse (RN) is responsible for executing a streamlined approach to receiving,… more
- Veterans Affairs, Veterans Health Administration (Phoenix, AZ)
- …AZ. It is a Level 1a major interdisciplinary teaching facility. The Chief Nurse , Sterile Processing Service is the administrative and accountable official for the ... within the organization. Responsibilities VA offers a comprehensive total rewards package: VA Nurse Total Rewards Duties Include but not limited to: The CN SPS… more
- Banner Health (Phoenix, AZ)
- …and regulatory agencies. MINIMUM QUALIFICATIONS Must possess knowledge of case management or utilization review as normally obtained through the completion of a ... of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through...in case management or health care. Requires current Registered Nurse (RN) license in state worked. For assignments in… more
- Evolent (Phoenix, AZ)
- …quality and cost effective care delivery. **What You'll Be Doing:** + Performs utilization review of outpatient procedures and ancillary services. + Fulfills on ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Banner Health (Phoenix, AZ)
- …management process. Reviews audit results and presents summary information for management utilization and review . 7. May coordinate the admission process ... facilities in the Phoenix Metro area. Exemplars mentioned from the American Nurse Credentialing Center included the robust nursing succession planning and the… more
- Banner Health (Mesa, AZ)
- …and advanced procedures. Our Endoscopy Unit maintains 6 procedural rooms, along with utilization of the OR, as needed. Nursing careers are better at Banner Health. ... differential, when applicable.** If you are a New Graduate Nurse with less than 12 months of experience, please...that includes the da Vinci Surgical System. Becker's Hospital Review named Banner Desert Medical Center as one of… more
- Banner Health (Phoenix, AZ)
- …and regulatory agencies. MINIMUM QUALIFICATIONS Must possess knowledge of case management or utilization review as normally obtained through the completion of a ... and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements. 6. Educates internal members of the health… more
- Banner Health (Scottsdale, AZ)
- …management process. Reviews audit results and presents summary information for management utilization and review . 7. May coordinate the admission process ... care under the direction and supervision of a registered nurse and/or licensed physician, and is accountable for the...Contributes to plan of care under direction of registered nurse , including the discharge plan, utilizing assessment data and… more
- CVS Health (Phoenix, AZ)
- …And we do it all with heart, each and every day. Review complex clinical criteria-based prior authorizations (electronically and/or in written format) in ... * Refer prior authorization cases not meeting clinical criteria for upper-level review when appropriate. * Must possess excellent communication skills, both written… more
- Molina Healthcare (Chandler, AZ)
- …care unit (ICU) or emergency room. Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / ... JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically… more
- Molina Healthcare (Chandler, AZ)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member… more
- Molina Healthcare (Chandler, AZ)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At least 2… more
- Molina Healthcare (Chandler, AZ)
- …in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * Provides leadership ... the chief medical officer. * Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the… more
- Molina Healthcare (Chandler, AZ)
- …the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the ... and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource… more
- Molina Healthcare (Chandler, AZ)
- …accreditation surveys and regulatory audits through documentation validation and process review . + Prepares accurate and timely audit reports summarizing outcomes, ... findings and recommended corrective actions. + Performs audits in utilization management, care management, member assessment, behavioral health, and/or other… more
- Highmark Health (Phoenix, AZ)
- …of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member ... Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a ...data to assure appropriate level of payment and resource utilization . It is also used to identify issues which… more