- AmeriHealth Caritas (Palm Beach Gardens, FL)
- …information necessary to perform a thorough medical necessity review . It is within Clinical Care Reviewer UM discretion to pend requests for additional ... administrative services. Discover more about us at www.amerihealthcaritas.com. ; **Responsibilities:** The Clinical Care Reviewer will be scheduled to CORE… more
- Evolent (Tallahassee, FL)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer you will be a key member of the utilization ... provides clinical rationale for standard and expedited appeals. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the MD… more
- Centers Plan for Healthy Living (Margate, FL)
- …currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will...care managers and believe that coordinating high quality clinical and social services will result in better … more
- Elevance Health (FL)
- …reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.** + Collaborates with healthcare providers, and ... Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. + Partners… more
- Elevance Health (Tampa, FL)
- …Florida. + Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and/or minimum of 3 years of managed care ... equivalent. + Requires a minimum of 2 years of clinical experience and/or utilization review ...interpret and apply member contracts, member benefits, and managed care products is strongly preferred. + Proficient in Microsoft… more
- Genesis Healthcare (Oxford, FL)
- …rehabilitation department, including oversight related to case management, quality improvement, care planning, clinical utilization , and patient ... Director in the timely completion of the annual merit review for therapy staff. 6. Assists Clinical ...utilization with input from treating therapists, consideration of clinical requirements, and recommendations from the Clinical … more
- Centene Corporation (Tallahassee, FL)
- …assess ABA Treatment Plans preferred. + Knowledge of ABA services and BH utilization review process preferred. + Experience working with providers and healthcare ... Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care ...teams to review care services related to Applied Behavior… more
- BayCare Health System (Clearwater, FL)
- …that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence. **The Utilization Review Specialist Senior responsibilities ... discounts and more _Equal Opportunity Employer Veterans/Disabled_ **Position** Utilization Review Spec Sr **Location** Clearwater:Morton Plant | Clinical |… more
- Humana (Tallahassee, FL)
- …Lung or Critical Care Nursing experience required + Previous experience in utilization management required + Prior clinical experience preferably in an acute ... first** Humana Healthy Horizons in Ohio is seeking a Utilization Management Nurse 2 who utilizes clinical ... care , skilled or rehabilitation clinical setting + Comprehensive knowledge of Microsoft Word, Outlook… more
- Centene Corporation (Tallahassee, FL)
- …of Florida **Position Purpose:** Supervises the behavioral health (BH) utilization review clinicians to ensure appropriate care for members and supervises ... of BH utilization management team. + Monitors behavioral health (BH) utilization review clinicians and ensures compliance with applicable guidelines +… more
- Cleveland Clinic (Weston, FL)
- …the responsibilities of a Utilization Management Specialist include medical record review , providing clinical information to payers, UM data collection and ... Utilization Management Specialist Join Cleveland Clinic Weston Hospital's...UM activities, such as admission review , concurrent review , retrospective chart review and clinical… more
- AdventHealth (Daytona Beach, FL)
- …practice as a Registered Nurse + Minimum three years acute care clinical nursing experience + Minimum two years Utilization Management experience + Excellent ... of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines,...qualifications:** + Bachelor of Science in Nursing (BSN) + Clinical experience in acute care facility -… more
- Molina Healthcare (Orlando, FL)
- …management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy ... delegated by the Manager. + Identifies and implements programs to improve clinical outcomes stemming from medication selection, utilization , and adherence. **JOB… more
- Community Health Systems (Sarasota, FL)
- (Full-Time, Remote) The Clinical Review Auditor is a professionally licensed nurse/LPN who is responsible for effectively managing the denial/appeal process via ... for care delivered to patients in a dynamic changing environment. As an Clinical Review Auditor at Community Health Systems, you'll play a vital role in… more
- Highmark Health (Tallahassee, FL)
- …weekdays** This job implements effective utilization management strategies including: review of appropriateness of health care services, application of ... licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided. **Preferred** + Certification in … more
- HCA Healthcare (Tallahassee, FL)
- …we encourage you to apply for our Adv Clinical Pharmacist Critical Care opening. We promptly review all applications. Highly qualified candidates will be ... Do you have the career opportunities as an Adv Clinical Pharmacist Critical Care you want with...for the safe, effective, evidence-based, and cost-effective selection and utilization of medications for the patients in the ICU.… more
- Evolent (Tallahassee, FL)
- …Participates in the development and implementation of new strategies to make the clinical review process more efficient through people, processes, and technology ... primary care , we seek to ensure that care plans align with clinical evidence, respect...of physician, nursing, and shared services staff in the utilization management value chain + Owns clinical … more
- CVS Health (Tallahassee, FL)
- …expense reimbursement policy **Preferred Qualifications** + Crisis intervention skills + Managed care / utilization review experience + Case management and ... optimal, cost-effective outcomes. Assessment of Members: -Through the use of clinical tools and information/data review , conducts comprehensive assessments of… more
- CenterWell (Port Charlotte, FL)
- … of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts ... put health first** Naples/ Bonita Springs/ Estero areas The ** Clinical Manager** coordinates and oversees all direct care...requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking… more
- CVS Health (Miami, FL)
- …Suite applications (Teams, Outlook, Word, Excel, etc.) **Preferred Qualifications** + Managed care / utilization review experience + Case management and ... overall health through integration. + Through the use of clinical tools and information/data review , conducts comprehensive...strategies designed to reduce risk factors and address complex clinical and social indicators which impact care … more