- 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
- 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
- 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
- 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
- Humana (Boston, MA)
- …hoc reports in Access and/or SQL + Graduate degree + Utilization Management Review Experience + Registered Nurse ( RN ) Credentials + Home Health, ... Durable Medical Equipment, and/or Skilled Nursing Facility Experience **Additional Information** **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week)… more
- Tufts Medicine (Tewksbury, MA)
- …etc.) **Job Description** **Minimum Qualifications:** 1. Bachelor's degree in Nursing (BSN). 2. Registered Nurse ( RN ) license. 3. Basic Life Support (BLS) ... expectations, continuing education, credentialing, performance appraisals, auditing, concurrent monitoring, utilization review , risk management and active… more
- Tufts Medicine (Burlington, MA)
- …**Job Description** **** **Minimum Qualifications:** 1. Associate's degree in Nursing 2. Active Registered Nurse ( RN ) license in Massachusetts or compact ... hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) OR case management , utilization review , or denials management in an acute-care… 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
- 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
- Commonwealth Care Alliance (Boston, MA)
- …plans. Community Health Workers (CHWs) are key members of interdisciplinary care management teams and complement and support each enrollee's needs, goals, and ... improve CCA enrollee outcomes by impacting care access and utilization , closing of care quality gaps, and optimizing member...manner; promote and enforce the CCA compliance program + Review the Code of Conduct at least annually and… more
- Commonwealth Care Alliance (Boston, MA)
- …claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required + 7+ years experience with Optum Claims ... Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr....regulations. The role will also be responsible for timely review and research, as necessary on all new and… more
- Commonwealth Care Alliance (Boston, MA)
- …claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required + Extensive knowledge and experience in ... Working under the direction of the Sr. Director, TPA Management and Claims Compliance, the Payment Integrity (PI) Recovery...strategies to prevent future occurrences, with the ability to review impacts holistically. + Assist in the development of… more
- Beth Israel Lahey Health (Danvers, MA)
- …application of Quality Assurance and Customer Service Programs, implementation of Utilization Review mechanisms; structuring clinical supervision; provision of ... $7500 (prorated for part-time)** + **Day 1 Benefits!** The Nurse Manager is responsible for the management ...daily operations of the program by providing supervision to RN 's and LPN's. This is a great opportunity to… more
- HealthEdge Software Inc (Boston, MA)
- …support people need, when and where they need it. We call it Digital Health Management . Our comprehensive suite of Digital Health Management solutions for care ... both clinical outcomes and the member experience. **What you bring:** + ** RN /NP/MSN** with **10+ years of health care experience** **required** ; ideally with… more