- Apex Health Solutions (Houston, TX)
- Summary: The UM Reviewer serves as a contact...utilization review (UR) of healthcare services. The UM Reviewer will be responsible for complying ... or UR questions or issues arise. To support care management initiatives, the UM Reviewer should also identify enrollees in need of case/disease management… more
- Molina Healthcare (Houston, TX)
- …clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review , patient education, and medical staff interaction), and oversight (establishing ... and medication use policies). **KNOWLEDGE/SKILLS/ABILITIES** The Lead Pharmacist, Utilization Management ( UM ) will serve as a team lead to support the pharmacy… more
- Molina Healthcare (Houston, TX)
- **JOB DESCRIPTION** Opportunity for experienced Utilization Review RN in United States who has a compact, multi-state license. This team reviews the prior ... the ideal candidate will have experience either in utilization review or case management for transplants. Preference will be...for transplants. Preference will be given to those whose UM experience is within another MCO like Molina; experience… more
- Molina Healthcare (Houston, TX)
- …topics using clinical expertise gained through previous experience in either UM or CM. Applies critical thinking skills, clinical/professional judgement, and breaks ... proper clinical judgment and approaches to decision making. Draws upon previous CM/ UM experience to direct trainees and provide them with best practices for… more
- Molina Healthcare (Houston, TX)
- **EMERGENCY ROOM ADMISSIONS REVIEW NURSE** **_2 openings for 12 hour NIGHT SHIFT: 7:30PM (in the evening) - 08:30AM (in the morning) PACIFIC HOURS NON EXEMPT, 3 days ... Collaborates with multidisciplinary teams to promote Molina Care Model. + Adheres to UM policies and procedures. + Occasional travel to other Molina offices or… more
- Molina Healthcare (Houston, TX)
- …with multidisciplinary teams to promote Molina Care Model. + Adheres to UM policies and procedures. **JOB QUALIFICATIONS** **Required Education** Graduate from an ... Accredited School of Nursing. **Required Experience** 3+ years hospital acute care/medical experience. **Required License, Certification, Association** Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's… more
- Molina Healthcare (Houston, TX)
- …Collaborates with multidisciplinary teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other Molina offices or ... hospitals as requested, may be required. This can vary based on the individual State Plan. + Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings. **JOB QUALIFICATIONS** **Required… more
- Houston Methodist (Houston, TX)
- …other areas according to department specifications. + Manages utilization management ( UM ) programs including Medical Claims Review , Precertification and ... competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees,… more
- Kelsey-Seybold Clinic (Pearland, TX)
- …Services is accountable for activities and personnel related to Utilization Management ( UM ) and Claims auditors to manage both delegated commercial and Medicare ... Benefit products. Manage all aspects of utilization review and claims in accordance with regulatory and accreditation...to monitoring performance and reporting compliance issues to maintain UM and Claims delegation. Primary contact for UM… more
- Molina Healthcare (Houston, TX)
- …The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as ... Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees. + Participates as needed in Joint Operation Committees (JOC's) for… more
- Molina Healthcare (Houston, TX)
- …with new databases, report monitoring, BOTs/Automation, etc. + Monthly business review meeting with executive leadership team, business stakeholders and ensures the ... coaches, counsels and evaluates performance of direct reports. + Team management Performance review of team members at regular intervals Other duties which are of… more
- Molina Healthcare (Houston, TX)
- …appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership ... requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial process. + Monitors appropriate care and services… more
- Kemper (Houston, TX)
- …and resolve moderate to severe, including fatal, bodily injury claims with prompt review and respond to all demands, including time limit demands + Obtain and ... negotiate settlements with claimants and attorneys + Adjust insurance policies for UM /UIM claims **Position Qualifications** : + High School Diploma or GED required… more