- Molina Healthcare (Dayton, OH)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- Elevance Health (Mason, OH)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- Elevance Health (Mason, OH)
- ** Nurse and CPC - Clinical Fraud Investigator II -...control. + Review and conducts analysis of claims and medical records prior to payment. Researches ... + Performs in-depth investigations on identified providers as warranted. + Examines claims for compliance with relevant billing and processing guidelines and to… more
- Molina Healthcare (Dayton, OH)
- … claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider ... policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or… more
- Molina Healthcare (Dayton, OH)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- CVS Health (Franklin, OH)
- …holidays, and flexibility as you coordinate the care of your members. + Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...+ Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit… more
- CVS Health (Union, OH)
- …paid holidays, and flexibility as you coordinate the care of your members. Nurse Case Manager is responsible for telephonically and/or face to face assessing, ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...wellness. Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit… more
- Elevance Health (Mason, OH)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. + ... make an impact:** + Managing incoming calls or incoming post services claims work. + Determines contract and benefit eligibility; provides authorization for… more