- Harbor Health Services, Inc. (Mattapan, MA)
- …for more than 580 participants. We are currently seeking a Director of Utilization Management & Quality Programs. Harbor Health offers an excellent, ... Reporting to the Senior Director of Health Plan Operations, the Director of Utilization Management and Quality Programs is responsible for the day-to-day… more
- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- CenterWell (Boston, MA)
- … RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers...DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous… more
- Elevance Health (Woburn, MA)
- ** Nurse Reviewer I** **Virtual:** This role...hospital setting or minimum of 1 year of prior utilization management , medical management and/or ... time,** **with rotating weekends.** **New Grads are encouraged to apply!** The ** Nurse Reviewer I** will be responsible for conducting preauthorization, out… more
- CVS Health (Boston, MA)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …true colors to blue. The Role:The Compliance Program Consultant will focus on utilization management compliance and audit readiness activities such as evaluating ... Medical Management 's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations. The Team:… more
- Beth Israel Lahey Health (Cambridge, MA)
- …SKILLS, AND ABILITIES REQUIRED** 1. RN with experience in risk management , quality assessment, or utilization management . 2. Strong spreadsheet, ... on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of...reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review … more
- Beth Israel Lahey Health (Burlington, MA)
- …the medical necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized ... Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the...necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue… more
- Beth Israel Lahey Health (Burlington, MA)
- …**Essential Duties & Responsibilities including but not limited to:** 1) Performs utilization review and discharge planning to inpatient admissions. 2) Applies ... to meet the needs of the department. **Minimum Qualifications:** Education: * Registered Nurse , Bachelors Degree or commensurate experience preferred. Licensure,… more
- Massachusetts Institute of Technology (Cambridge, MA)
- …patients, families, providers, and community agencies. PREFERRED: two years of case management , utilization review , and discharge planning experience. ... Registered Nurse , Care Coordinator + Job... Registered Nurse , Care Coordinator + Job Number: 25320 +...Graduate of an accredited nursing program; bachelor's degree; current RN license in Massachusetts; CPR Certified; a minimum of… more
- Lawrence General Hospital (Methuen, MA)
- … experience in an acute care setting with discharge planning, continuing care, care management , and utilization review preferred. ? Strong verbal and written ... Job Description: The RN Care Coordinator is responsible for overseeing the...of the Hospital on a rotating basis to perform utilization reviews and other UM activities, as needed, to… more
- Fresenius Medical Center (Peabody, 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
- Lawrence General Hospital (Methuen, MA)
- … experience in an acute care setting with discharge planning, continuing care, care management , and utilization review preferred. + Strong verbal and written ... below the top of the range to support future salary growth. The RN Care Manager collaborates with physicians, nurses, and other clinical staff/directors to… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. * Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management * Serve as the primary relationship manager and point of contact… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Intermountain Health (Boston, MA)
- …of Intermountain Health, and abide by service behavior standards. **Minimum Qualifications** + Current Registered Nurse ( RN ) license in state of practice. + ... **Job Description:** The RN Ambulatory Care Manager I delivers comprehensive ambulatory... Management Certification + Demonstrated experience in case management , utilization review , or discharge… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred. + Active licensure in Massachusetts is ... Bring your true colors to blue. The Role The RN Case Manager is responsible for facilitating care for...standards to create, follow and appropriately document comprehensive care management plans. + Review medication list and… 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
- Humana (Boston, MA)
- …**Use your skills to make an impact** **Required Qualifications** + Licensed as a Registered Nurse in the State of Wisconsin, including compact license. + Two ... put health first** Humana is seeking a Prior Authorization RN to join the Wisconsin Medicaid Market (iCare) team....the lives of others. **Essential Duties and Responsibilities:** + Review PA requests for home health services, durable medical… more
