- Baylor Scott & White Health (Columbus, OH)
- …and members. **Key Success Factors** + Demonstrable knowledge in discharge planning, case management , utilization review and different care levels. + ... type and/or level **Job Summary** As a Manager for Utilization Review , you guide and supervise staff....work experience + Hold a valid registration as a Registered Nurse As a health care system… more
- Molina Healthcare (Columbus, OH)
- …Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG ... guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). **MULTI STATE / COMPACT… more
- CVS Health (Columbus, OH)
- …Assessment of Members through the use of clinical tools and information/data review , conducts comprehensive evaluation of member's needs and benefit plan eligibility ... -Application and/or interpretation of applicable criteria and guidelines, health/wellness management plans, policies, procedures, regulatory standards while assessing benefits… more
- Molina Healthcare (Columbus, OH)
- For this position we are seeking a ( RN ) Registered Nurse who lives in OHIO or KENTUCY and must be licensed for the state they reside Clinical Auditor RN ... **KNOWLEDGE/SKILLS/ABILITIES** + Performs monthly auditing of registered nurse and other clinical functions in Utilization ... nurse and other clinical functions in Utilization Management (UM), Case Management … more
- Highmark Health (Columbus, OH)
- …and Sunday required in addition to 3 weekdays** This job implements effective utilization management strategies including: review of appropriateness of ... and offers interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established… more
- CVS Health (Columbus, OH)
- …reimbursement policy. + 1+ year of Coding experience **Preferred Qualifications** + Utilization Management review + Managed Care experience **Education** ... are 8am-5pm in time zone of residence.** **Position Summary** RN and certified coder Responsible for the review...experience required + 2+ years of experience as a Registered Nurse + Must have active, current… more
- CVS Health (Columbus, OH)
- …may include weekends, holidays and evening hours._ This is a full-time remote Utilization Management opportunity. + Utilizes clinical experience and skills in a ... zone + 3+ years of clinical experience as a Registered Nurse in a hospital setting including...with a late shift rotation 10:30am to 7pm EST. Utilization management is a 24/7 operation. Work… more
- Humana (Columbus, OH)
- …Family Therapist **(LMFT)** , Licensed Professional Counselor **(LPC)** , Psychologist **(PhD)** , Registered Nurse **( RN )** or other professional license. + ... us put health first** Humana Healthy Horizons in Kentucky is seeking a Utilization Management Behavioral Health Professional 2 who utilizes behavioral health… more
- Molina Healthcare (Columbus, OH)
- …of payment decisions. + Serves as a clinical resource for Utilization Management , Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. ... SKILLS & ABILITIES:** + Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years… more
- Molina Healthcare (Columbus, OH)
- … Registered Nursing ( RN ) license in good standing. + Utilization Management Certification (CPHM) Certified Professional in Health Care Quality (CPHQ), ... and results across Molina Health Plans & Segments. **KNOWLEDGE/SKILLS/ABILITIES** + Review existing case management standards and processes and establishes… more
- Guardian Life (Columbus, OH)
- …services. Act as a liaison between all parties required in case management to facilitate collaboration toward RTW goals. Utilization of independent ... **Position Summary** The RN Clinical Consultant serves as a clinical resource...issues, when possible, to enhance the customer experience. **Activity** Review and assess claimant subjective reports and objective medical… more
- AmeriHealth Caritas (Dublin, OH)
- …complete, and accurate documentation of Member interactions in ACFC electronic care management platforms where applicable. + Monitor appropriate utilization and ... it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other… more
- Fresenius Medical Center (Columbus, OH)
- …meetings may be required. **SUPERVISION:** **None** **EDUCATION AND REQUIRED CREDENTIALS:** * Registered Nurse required *Certification in Nephrology Nursing or ... barriers to quality improvement. This includes promoting the adoption and utilization of Medical Advisory Board Recommended Algorithms and Standing Orders, clinical… more
- CVS Health (Columbus, OH)
- …visit, inpatient, skilled nursing, or rehabilitative stay. Under the direction of a Registered /Licensed RN , the TOC Coach ensures the member experiences a ... or changes in condition to be transitioned back to RN . + Complete post discharge call and required assessments...Complete inpatient confinement calls and monitor for discharge. + Management of warm transfers from concierge and engagement hub… more