- CVS Health (Raleigh, NC)
- …all with heart, each and every day. **Position Summary** Medicare Precertification Utilization Management Nurse Consultant position: _Utilization ... with occasional holiday rotation.** **Preferred Qualifications** + Prior Authorization or Utilization Management experience + Managed care experience +… more
- CVS Health (Raleigh, NC)
- …we do it all with heart, each and every day. **Position Summary:** The ** Utilization Management Clinical Nurse Consultant - Prior Authorization** utilizes ... Time_ ). + Previous experience with prior authorization. + Previous experience with utilization management . + Previous experience in an acute care setting. +… more
- Humana (Raleigh, NC)
- **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
- Cognizant (Raleigh, NC)
- …background - Registered Nurse (RN) + 2-3 years combined clinical and/or utilization management experience with managed health care plan + 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations + Experience in utilization management to include Clinical Appeals and… more
- UNC Health Care (Raleigh, NC)
- …stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is ... case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management… more
- CVS Health (Raleigh, NC)
- …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 (Raleigh, NC)
- …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 (Raleigh, NC)
- …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 (Cary, NC)
- …direction of the Facility Manager, Director of Nursing and/or Charge Registered Nurse , utilizing standard nursing techniques to assist the physician in optimum ... on adverse events and action thresholds in collaboration with facility management . + Maintains integrity of medical records and other organization administrative… more
- Fresenius Medical Center (Garner, NC)
- …Classification of Disease (ICD) coding. + Manages clinic financials including efficient utilization of supplies or equipment and regular profits and loss review. + ... + Preferred but not required: + 3+ years supervisory or project/program management experience. + Med/surg or ICU/CCU experience. **PHYSICAL DEMANDS AND WORKING… more
- UNC Health Care (Smithfield, NC)
- …of care and cost effectiveness through the integrating and functions of case management , utilization review and discharge planning. The Care Manager must be ... discharge plan. Refer administrative tasks (eg, faxing, form processing) to Care Management Assistant. Consult Social Worker and/or Utilization Manager per… more
- CenterWell (Lillington, NC)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts ... problems, identifies and evaluates alternative courses of action through the utilization of Performance Improvement principles. + Responsible for review of the… more
- CenterWell (Raleigh, NC)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts ... problems, identifies and evaluates alternative courses of action through the utilization of Performance Improvement principles. + Responsible for review of the… more
- Sharecare (Raleigh, NC)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Highmark Health (Raleigh, NC)
- …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
- UNC Health Care (Garner, NC)
- …7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely ... plans are evidence-based, culturally sensitive, and promote patient engagement and self- management . 3. Risk Segmentation: a. Utilize standardized tools and clinical… more
- CVS Health (Raleigh, NC)
- …health outcomes by engaging telephonically with individuals living with diabetes. This nurse will guide members through actionable steps to close gaps in care, ... education, connecting members to resources, and facilitating referrals to care management programs for continued support. This position supports the development and… more
- Deloitte (Raleigh, NC)
- …to collaborate with clinicians, physicians, NP/PAs, ancillary departments, Quality, Case Management , Finance, Revenue Cycle, and Coders + Other skills include the ... both formal and informal education of physicians, CDI team, health information management and other clinical staff + Develop in-service education tools as necessary… more
- Oracle (Raleigh, NC)
- …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