- Humana (Frankfort, KY)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- CVS Health (Frankfort, KY)
- …and external constituents in the coordination and administration of the utilization /benefit management function. + Utilizes clinical skills to coordinate, ... document and communicate all aspects of the utilization /benefit management program. **Required Qualifications** + Must...state licensure (LCSW, LPCC, LMFT, LPAT) or a Registered Nurse (RN) with active current and unrestricted Kentucky state… more
- Molina Healthcare (Lexington, KY)
- …chief medical officer on denial decisions. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * ... JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for internal appeals clinical processes...be required. * Serves as a clinical resource for utilization management , chief medical officer, physicians, and… more
- CVS Health (Frankfort, KY)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Abuse or Maternity/ Obstetrics experience. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… more
- Evolent (Frankfort, KY)
- …Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed ... medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum… more
- Evolent (Frankfort, KY)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and… more
- Fresenius Medical Center (Georgetown, KY)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Molina Healthcare (Lexington, KY)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
- Molina Healthcare (Lexington, KY)
- …services professionals in some or all of the following functions: care management , utilization management , behavioral health, care transitions, long-term ... For this position we are seeking a (RN) Registered Nurse and/or a Licensed Social Worker who lives in...* Assists in implementing health management , care management , utilization management , behavioral health… more
- Molina Healthcare (Lexington, KY)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of… more
- Highmark Health (Frankfort, KY)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... itemized bills, and claims data to assure appropriate level of payment and resource utilization . It is also used to identify issues which can be used for education… more
- Molina Healthcare (Lexington, KY)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high… more
- Oracle (Frankfort, KY)
- …alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal candidate ... sessions, and offer ongoing consultation to support user proficiency and system utilization . Monitor project outcomes, track key metrics, and report progress to… more
- HCA Healthcare (Lexington, KY)
- …and performance of assigned home health care team(s)Supervises ongoing case management of all patients ensuring an accurate evaluation and treatment plan, ... records reflect compliance with medical necessity, homebound status, visit utilization , and documentation of individualized patient assessment and transition… more